Individual Eligibility and Enrollment for the OPWDD HCBS 1915(c) Waiver and Requests for Service Authorization

New York State’s Office for People With Developmental Disabilities (OPWDD) maintains a statewide Medicaid waiver approved by the federal Centers for Medicare and Medicaid Services (CMS). This waiver is formally known as the OPWDD Comprehensive Home and Community-Based Services (HCBS) 1915(c) Waiver (HCBS Waiver) and authorizes an array of community-based habilitation services to eligible individuals with developmental disabilities. The available services are Day Habilitation, Prevocational Services, Residential Habilitation, Community Habilitation, Respite, Supported Employment, Pathway to Employment, Live-In Caregiver, Community Transition Services, Fiscal Intermediary, Individual Directed Goods and Services, Support Brokerage, Family Education and Training, Intensive Behavioral Services, Assistive Technology – Adaptive Devices, Environmental Modifications, and Vehicle Modifications. The terms of the HCBS Waiver agreement with CMS, which is part of the U.S. Department of Health and Human Services, require OPWDD to oversee providers of HCBS and to enforce the HCBS Waiver rules. A key component of OPWDD’s role is to ensure that HCBS are only delivered to eligible individuals under the HCBS Waiver’s rules. This ADM describes how OPWDD establishes HCBS Waiver eligibility including level of care, appropriate residential settings, and New York State residency status. The Guidance further describes how OPWDD evaluates the requirement that a person’s need for HCBS Waiver services is demonstrated through a “Reasonable Indication of Need” evaluation.