Office for People With Developmental Disabilities

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Eligibility FAQs

12/05/12

What is Eligibility?  

People who have special conditions called “developmental disabilities” can apply for OPWDD supports and services. These supports and services are meant to provide help throughout life for people with the greatest level of need for supports. Each person who wants OPWDD supports or services has the right to an individual eligibility review. That review will determine whether he or she has a condition that qualifies – or makes the person “eligible” -- for services or supports from OPWDD.
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Who may ask for a review of eligibility for OPWDD supports or services?

Individuals, or their caregivers, guardians, advocates, or care coordinators who help them, may apply to get supports or services provided or paid for by OPWDD. The application and review process is called the Eligibility Determination Process.
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Who decides whether a person is eligible for OPWDD services?

Only OPWDD can determine whether a person has a developmental disability and meets all the conditions of eligibility for OPWDD- funded services.
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What is required for a person to be eligible for OPWDD services?

This is what the New York State Mental Hygiene Law requires in order to be eligible for OPWDD services:

  1. The presence of a developmental disability that is described by certain qualifying diagnoses, or conditions 
  2. The disability has occurred before the person reached age twenty-two
  3. The disability can be expected to continue indefinitely, or permanently
  4. The disability causes a substantial handicap to a person’s ability to function normally in society

Read Section 1.03(22) of the New York State Mental Hygiene Law.

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What are developmental disabilities?

Developmental disabilities are special conditions that may occur anytime from before a baby’s birth, up until the age of 22. A developmental disability may take different forms. They are different from “developmental delays,” that show up as a lag in one or more areas of growth or skill. Developmental delays can be reduced by providing Early Intervention services and special help in the classroom. A developmental disability condition may cause a child to develop more slowly all along, or to have physical difficulties and limitations, or have trouble learning and growing like other children in general. Sometimes an individual has more than one condition or disability.

For eligibility for OPWDD supports or services, the developmental disabilities that are defined as ‘qualifying conditions’ include: intellectual disability (known as “mental retardation” in Mental Hygiene Law),  autism, cerebral palsy, epilepsy, familial dysautonomia, and neurological impairment (injury, malformation, or disease involving the Central Nervous System). Read more about Developmental Disabilities.

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What does “substantial handicap” mean? 

For OPWDD eligibility, “substantial handicap” means that a developmental disability is so serious that it makes it very difficult for an individual to live everyday life independently and function ‘normally’ in society. Qualified professionals are trained to evaluate individuals for developmental disabilities and difficulties with everyday life and functioning. Read more information on Practitioners Qualified to Conduct Assessments

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What kinds of records are needed to show that a person meets all the requirements for OPWDD eligibility?

In general, the records for OPWDD eligibility review would include reports of current or recent psychological testing of the person’s intellectual functioning, a standardized evaluation of the person’s “adaptive” behavior functioning, a social/developmental (or psychosocial) history, and medical reports indicating the person’s health status. For children or adults with special medical conditions, genetic disorders, or neurological impairment, medical records that confirm the diagnosis of these conditions or disorders are required. Educational records (IEPs, report cards) can be helpful, too. The DDRO contact staff can answer additional questions, explain the records requirements in more detail, and advise applicants and their representatives about giving permission and requesting copies of evaluations and other records. See our Important Facts Sheet for more information on records.

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What is the OPWDD Eligibility Review and Decision Process?

The process for determining eligibility may involve 3 steps: 

  1. The OPWDD Developmental Disabilities Regional Office (DDRO) reviews all requests for eligibility determinations.  Each request must include documentation (copies of records) to provide proof and explain the reason the applicant believes he or she has a developmental disability.  Sometimes, it takes only the First Step review for the DDRO to decide that an individual is eligible for OPWDD services.  Sometimes additional information is needed.  If the First Step reviewers decide that a person is not eligible, the referral must still be reviewed by a different set of reviewers.  Then, and in more complicated cases, the DDRO may request that a special team of OPWDD experts review the application for a second time.   These types of reviews are called a “Second Step Review.”
  2. During or after the Second Step Review of an application, the reviewers may request more information, or recommend a face-to-face meeting with the person and his or her representatives. If a person is found to be ineligible, a face-to-face meeting with the Second Step reviewers can also be requested, to discuss the reasons for that decision.  If a person is found eligible at Second Step, the DDRO will send a letter to notify the person.   A person who is found to be not eligible at this point may ask for a Third Step review. The person can also send in additional/new information.
  3.  A Third Step Review is completed by a team of OPWDD statewide experts.  The Third Step reviewers may find the person to be eligible, or may agree that the person does not meet the requirements for eligibility. 
    • Individuals who have asked for specific Medicaid services may request a Fair Hearing if they do not agree with an OPWDD eligibility determination. OPWDD.
    • For more information, see our Eligibility for OPWDD Services "Important Facts" document.

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How is eligibility determined for children?

For children between birth and eight years of age, the eligibility review requirements are the same as those for adults, although the qualifying condition requirement leaves room for flexibility. Sometimes, children will be given provisional eligibility for OPWDD supports or services. Read more information on Provisional Eligibility.

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What is “Provisional Eligibility”?

In some cases, based on clinical judgment of a child’s needs, the DDRO may decide to give provisional eligibility to a child. Provisional eligibility means that a child may get OPWDD supports or services for a limited period of time. Before the end of the time period, OPWDD must review updated information about the child’s condition and functioning to see if the child is still eligible for supports or services. The reason that some children have provisional eligibility is that they may have qualifying levels of delays in development that can still change or improve as they grow older. All children with provisional eligibility must be reviewed again before their eighth birthday, but some may be reviewed earlier. The DDRO will decide when the child should be evaluated again, and whether a child who has had provisional eligibility is still eligible for OPWDD supports or services.

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What is a “qualifying level of delay in development” for children?

New York State Education Law has standards that explain how to measure the possible kinds and levels of delay that a child under eight years of age may have. These rules help to determine how much the child’s delay affects the child’s ability to live a normal life. This information about the kind and level of delay in development is usually contained in a report that is reviewed for OPWDD eligibility.

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Is there any age limit for applying for OPWDD eligibility?

There are no age limits for requesting OPWDD eligibility. Eligibility status can be reviewed from infancy throughout a person’s life. It is important to be aware, however, that a person’s age can affect the ability to find proof of the disability before age 22. As a person gets older, it may become more difficult to find the records and reports from schools, clinics, hospitals, and other settings that could show how a person’s condition met the age requirement for OPWDD eligibility.

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How does OPWDD work with children who are over the age for school or social service programs, and may need adult services?

OPWDD works closely with school, foster care, and other programs that provide services to children to plan for the time when children become too old (or “age out”) to receive services from them. Usually, children become too old for children’s services when they turn 21 years old.

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Where can I obtain additional information on how OPWDD determines eligibility for services?

In 2001, OPWDD established a policy advisory guideline that explains how the agency confirms the presence of developmental disability or substantial handicap. The advisory guideline also explains clinical issues related to eligibility for OPWDD services. For more information, refer to the OPWDD Advisory Guideline.

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