New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIV - Office for People With Developmental Disabilities
Part 629 - Eligibility for Services
Section 629.1 - Eligibility Determination Process

(i) Provisional eligibility may be determined in children, up to the age of seven, who manifest substantial delays, with or without 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. They must also be a New York State resident or intend to reside in New York State at the time that services are delivered.

(ii) Provisionally eligible children who reach their 7th birthday cannot be authorized for additional services until a final eligibility determination has been made by OPWDD, except in extraordinary circumstances upon the approval of the Commissioner or their designee.

(iii) Provisional eligibility must be redetermined by a child's 8th birthday. Children 7 years and older seeking OPWDD services must meet full OPWDD eligibility criteria.

(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.

(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:

(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:

(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.

(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 per son. 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