14 CRR-NY 629.1NY-CRR
14 CRR-NY 629.1
14 CRR-NY 629.1
629.1 Eligibility determination process.
(a) Applicability.
OPWDD will determine whether individuals are eligible for OPWDD operated, certified, funded and/or authorized services (hereinafter services).
(b) General eligibility provisions.
(1) Eligibility is determined by the application of consistent criteria based on the definition of developmental disability established in Mental Hygiene Law (MHL) section 1.03(22).
(2) Provisional eligibility may be determined in children, up to the age of eight, who manifest substantial delays, or specific congenital or acquired conditions that result in a high probability of a developmental disability if services are not provided, and whose condition and/or functioning may improve significantly over time, as a result of treatments and services.
(3) OPWDD may review or re-review an individual’s eligibility at any time. Applicants determined ineligible may reapply for services upon receipt of new or differing information that supports eligibility at any time.
(4) OPWDD, through its Developmental Disabilities Regional Office (DDRO), is responsible for determining whether a person is eligible for OPWDD services. A three-step process, as described herein, is used by OPWDD to make an eligibility determination of developmental disability.
(5) A determination that a person is eligible to receive OPWDD services based on the individual meeting the criteria for a developmental disability does not mean the person is automatically eligible for all OPWDD services, as some OPWDD services have additional eligibility criteria.
(c) Eligibility determination process.
(1) Eligibility request.
(i) A request for eligibility in a form and format specified by OPWDD must accompany all requests submitted to the DDRO for eligibility determinations. The request for eligibility includes the name of the person, the name of the person's representative, and relevant contact information. The request for eligibility also includes documentation of the person's developmental disability including information related to condition/diagnosis, standardized intelligence testing, standardized measures of adaptive functioning, information related to history and presence of disability prior to age 22, a full report of all contemporary diagnoses or classifications of health, physical, developmental, or psychiatric conditions that are relevant to the determination of eligibility, and other information that may be requested by OPWDD.
(2) 1st step review.
(i) DDRO staff review the eligibility request for completeness and share the information with staff designated by the director, as necessary. After this review, the DDRO notifies the person in writing that:
(a) eligibility or provisional eligibility has been determined; or
(b) the request requires additional documentation; or
(c) the request has been forwarded for a 2nd step review.
(3) 2nd step review.
(i) DDRO clinicians designated by the DDRO 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 information, the person is notified in writing of the type of information needed and the date by which it must be submitted to the DDRO.
(ii) Following the 2nd step review, the DDRO provides the individual with written notification of its determination. If the person is found ineligible for OPWDD services because he or she does not meet the criteria for a developmental disability, as defined in MHL section 1.03(22) and associated guidelines, the letter shall offer the person and his or her representative the opportunity to:
(a) meet with DDRO staff to discuss the determination and documentation reviewed; and/or
(b) request a 3rd step review; and/or
(c) request a Medicaid fair hearing in cases where Medicaid funded services are sought.
(iii) A notice of decision informing the person of his or her right to request a Medicaid fair hearing is sent only when the request for services indicates that the person is interested in receiving Medicaid funded services if determined eligible. If the person has not indicated Medicaid funded services, no fair hearing is required and the decision of the DDRO is final.
(iv) If a fair hearing is requested, a 3rd step review will automatically be conducted.
(4) 3rd step review.
(i) 3rd step eligibility determination committee conducts 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 DDRO. The DDRO considers the 3rd step recommendations and informs the person of any change in the DDRO's determination. 3rd step reviews will be made prior to any fair hearing date.
14 CRR-NY 629.1
Current through June 30, 2021
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