Office for People With Developmental Disabilities

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The Eligibility Review Process

11/10/16

Required Documentation for Eligibility Determination Requests

In order to determine if you are eligible for OWPDD services, the following information must be submitted to your local Developmental Disabilities Regional Office (DDRO) Eligibility Coordinator for review.  If you need assistance in determining how to go about securing a required report or assessment that you do not have, your eligibility coordinator can assist you.

  • A psychological report within 3 years 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. 
  • An interpretive report of adaptive behavioral assessment results.
  • For conditions other than intellectual (developmental) disability, a medical or specialty report which includes health status and diagnostic findings to support the diagnosis. 
  • A recent general medical report should be included in all eligibility requests.
  • A social/developmental history, psychosocial report or other report which shows that the person became disabled before age 22. 

In some cases, the DDRO may require additional information or further evaluation. The DDRO may  recommend where additional assessments can be completed. 

We recommend that you work with the Eligibility Coordinator at your local DDRO to ensure that you have submitted a complete eligibility packet when requesting an eligibility determination.

OPWDD’s Eligibility Determination Checklist can help keep you on track as you gather this needed information. 

The Eligibility Review Process:  What to Expect

Once you, your loved one or your advocate has submitted all the required paperwork and officially made an eligibility request through your local Developmental Disabilities Regional Office (DDRO), the review process to determine if you are eligible for services begins.

The 3-Step Eligibility Determination Process

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.

At the First Step, DDRO staff review the eligibility request to make sure it is complete. After this first review, the DDRO notifies the requestor in writing that: 

  1. Eligibility or Provisional Eligibility has been confirmed; or
  2. The request is incomplete and requires additional documentation; or
  3. The request is being forwarded for a Second Step Review

If your eligibility request is forwarded for a second step review, a committee of clinicians will evaluate the materials in your request file, and any additional information that you provide. 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.

When the Second Step Review is complete, the DDRO will send the requestor a written notice of the determination (also called a Notice of Decision). If the committee determines that the person does have a developmental disability, that person is deemed eligible for OPWDD services. If the committee determines that the person does not have a developmental disability, the person is deemed ineligible for OPWDD services. In that case, you will be able to

  1. Meet with OPWDD staff to discuss the determination and the documentation reviewed; and
  2. Request a Third Step Review; and
  3. Request a Medicaid Fair Hearing (if seeking Medicaid-funded services)

The person may choose any or all of these options. If a Medicaid Fair Hearing is requested, a Third Step Review will happen automatically. Please note that the Notice of Decision will only offer a Medicaid Fair Hearing 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 DDRO Second Step Review coordinator. The Third Step recommendations are considered by the DDRO Director (or designee) and the requestor is informed of the results, including any changes in the DDRO’s determination. Third Step Reviews are completed before Medicaid Fair Hearing dates.