Eligibility Review Process
The eligibility review process is the way OPWDD determines if you have a developmental disability or are eligible for supports and services.
The eligibility process begins at one of OPWDD's five Developmental Disability Regional Offices (DDROs) located throughout New York State. You and your family will need to submit materials and records, such as reports of assessments conducted by medical professionals. Your care manager may help you through this process.
The information you submit will be reviewed to see if your disability meets the requirements specified in New York State law. If it meets the requirements, you are deemed eligible for OPWDD services. (Please note: additional steps, such as enrolling in Medicaid, are needed to gain access to most supports and services.)
Depending on the complexity of your condition, the process for obtaining an eligibility determination may require reports from multiple specialty assessments. A face-to-face interview may also be part of the process.
Three-Step Eligibility Review
The process for determining eligibility may involve multiple review steps, and is designed to make sure that every person receives a fair and thorough review.
OPWDD staff review the eligibility request to make sure it is complete. After this first review, the regional office notifies you in writing that:
- (a) Eligibility or Provisional Eligibility has been confirmed; or
- (b) The request is incomplete and requires additional documentation; or
- (c) The request is being forwarded for a 2nd-Step Review
If your eligibility request is forwarded for a 2nd-step review, a committee of clinicians will evaluate the materials in your request ﬁle, and any additional information that you provide.
When the 2nd-step review is complete, the regional office will send you a written notice of the determination (also called a notice of decision or NOD). If the committee determines that you do have a developmental disability, you are eligible for OPWDD services. If you are found to be ineligible, you will be able to schedule a meeting with staﬀ to discuss that decision and to request a third step review. You can also request a Medicaid Fair Hearing at this point if you are seeking Medicaid-funded services. If a Fair Hearing is requested, a 3rd-Step Review will happen automatically.
*Please note that a Notice of Decision offering a Fair Hearing is sent only if the person has requested Medicaid-funded services on the Transmittal for Determination of Developmental Disability Form.
Third-step reviews are done by an independent Eligibility Review Committee of licensed practitioners not involved in the first- and second-step reviews. The committee reviews the eligibility request and provides recommendations to the second step review coordinator. The third-step recommendations are considered by the OPWDD Regional Office director (or designee) and the person is informed of the results, including any changes in the determination.
Third-step reviews are completed before the Fair Hearing date.
Required Documents for Eligibility Determination
The following information is needed to determine if a person is eligible for OPWDD services:
- A psychological report which includes an assessment of intellectual functioning (“IQ test”). This report should include all summary scores from the assessment (Full Scale, Index, Part and Subtest scores).
- For people with IQ scores above 60, an interpretive report of a standardized assessment of adaptive behavior, including summary, composite, scale, and domain scores, is required.
- For people with IQ scores below 60, an adaptive assessment may be based on an interpretive report using information gathered from interviews with caregivers, records review, and direct observations.
- For young children, an Early Intervention Multidisciplinary Core Evaluation may be acceptable provided it includes standardized rest scores relevant to cognitive, language and communicative, adaptive, social and motor functioning.
- For conditions other than intellectual disability, a medical or specialty report that includes health status and diagnostic findings to support the diagnosis. If available, a recent general medical report should be included in all eligibility requests.
- A social/developmental history, psychosocial report or other report that shows that the person became disabled before age 22. This is required for all eligibility requests.
In some cases, additional information or further evaluation may be requested to determine eligibility. We recommend that you work with the Eligibility Coordinator at your local OPWDD regional office to ensure that you have submitted a complete eligibility packet when requesting an eligibility determination.
The most critical component to determining eligibility is the diagnostic evaluation. A diagnostic evaluation is done to determine the nature and signiﬁcance of your developmental disability (i.e., your diagnosis.)
The Guide to Eligibility Assessment Resources in New York State includes OPWDD- certiﬁed clinics and the services they oﬀer.
Acceptable Measures of Intellectual and Adaptive Behavior
The following measures provide information about an individual’s intellectual functioning and adaptive behavior, which is needed for eligibility to be determined. You may wish to share this information with your doctor, or clinicians who will conduct these assessments.
Acceptable Measures of Intellectual Functioning
- The Wechsler series of intelligence scales
- The Stanford-Binet Scales
- Leiter International Performance Scale
- The Kaufman series of intelligence scales
Considerations for Measures of Intellectual Functioning:
- Brief or partial administration of comprehensive intellectual measures may only be used in circumstances where standardized administration is impossible.
- Abbreviated measures of intelligence (WASI, K-BIT) are not acceptable as the only measure of intellectual functioning.
- Language-free instruments (Leiter, CTONI) in combination with the Performance items of a comprehensive IQ test will be considered for individuals who do not speak English, are deaf, or are non-verbal
- Intelligence tests standardized in English cannot be administered in a diﬀerent language and then be used for eligibility determinations
Acceptable Measures of Adaptive Behavior
- Adaptive Behavior Assessment System
- Vineland Adaptive Behavior Scales
- The Motor Skills Domain only of the Scales of Independent Behavior
Other intelligence tests and/or adaptive behavior measures are acceptable if they are comprehensive, structured, standardized and have up-to-date general population norms. Results from a measurement that is not on this list, but was given prior to the person reaching age 22, can be used to establish a history of adaptive deﬁcits during the developmental period. Adaptive behavior measure ratings should reﬂect the person’s actual, typical behavior, not their best behavior under ideal circumstances or with assistance.
Please note: it is expected that current/updated evaluations of intellectual or adaptive functioning are based on the most recent editions of the standardized instrument used.
Forms to Accompany Eligibility Requests
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Important Facts About Eligibility
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