Step 2 – Determining Eligibility

To be able to access the majority of OPWDD services, most individuals will need to:

  • Provide evidence that they have a developmental disability
  • Enroll in a CCO for Care Management Services
  • Enroll in Medicaid (if needed), and
  • Enroll in the OPWDD Home and Community Based Services waiver (if needed)

What is Medicaid?

Medicaid is a joint federal-state health insurance program for people with low incomes and people with disabilities.  While people with intellectual and developmental disabilities (I/DD) receive health care through a variety of sources in the United States, most are enrolled in Medicaid.  They become eligible for it primarily through their eligibility for Supplemental Security Income (SSI) payments, which they receive because of their significant functional limitations and very low income or assets.

New York State has the same eligibility requirements for Medicaid as Supplemental Security Income (SSI) for people with I/DD.  This means if a person is receiving SSI, they will automatically qualify for Medicaid.  If you already receive SSI, then a separate application for Medicaid is not needed.

What are the Criteria for OPWDD Eligibility?

In order for a person to be eligible for OPWDD services, New York State Mental Hygiene Law requires:

  1. The presence of a developmental disability that is described by certain qualifying diagnoses or conditions,
  2. The disability occurred before the person reached age 22,
  3. The disability can be expected to continue indefinitely or permanently, and
  4. The disability causes a substantial handicap to a person’s ability to function normally in society.

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 that the disability was present before the person reached 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.

What documents are needed for OPWDD eligibility?

  • All available psychological evaluation reports which include an assessment of intellectual functioning.
  • Intelligence quotient (IQ) scores should be included.
  • Assessment of adaptive functioning (i.e. Vineland Adaptive Behavior Scale, Adaptive Behavior Assessment System (ABAS).
  • Relevant medical reports (e.g. MRI results, CT Scan results, neuropsychological reports).
  • Psychiatric reports.
  • Psycho-Social reports and/or social history.
  • Educational records including IEP or Annual 504 Accommodations Plans.
  • Any other documentation which verifies age of onset of significant functional limitation prior to age of 22.
  • A physical within the last 12 months.

How long does it take to establish OPWDD eligibility?

The eligibility process can take from 2-6 months.

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