May 2024- Community Class Updates

It has now been re-established that you have a right to a Fair Hearing-- details immediately below. If you are denied a community class, make sure that your Fiscal Intermediary is aware of the outcome of FH#8701340R, as summarized below. If you were denied a community class and did not get a Notice of Decision informing you of your Fair Hearing rights, then you can ask for a Fair Hearing on that denial no matter how long ago it was. We suggest you let the FI know that you intend to file for a Fair Hearing-- this might be enough to get them to re-consider. If you do have to go to a Fair Hearing, make explicit reference to Fair Hearing #8701340R. Provide a link to the official redacted findings for the Administrative Law Judge to review.

In Spring 2024 Fair Hearing FH#8701340R was won by the parents, on behalf of a young adult seeking reimbursement. The finding of the Fair Hearing was

1. When a community class is denied, the individual has the right to a fair hearing to review the facts.

2. The Administrative Law Judge (ALJ) used as the working definition of "duplicate": "explicitly offered instead of".

3. The ALJ rejected all criteria for denial that extended beyond the official docs: IDGS Definitions Chart and Self-Direction Guidance for Providers.

4. And in this case, a review of the facts found that the initial denial was incorrect.

The official findings:  otda.ny.gov/fair%20hearing%20images/2024-4/Redacted_8701340R.pdf 

The best parts are on pages 21 and 23

IDGS services through the HCBS waiver may be fully or partially New York State Medicaid-funded. Therefore, the Appellant has a right to a Fair Hearing to decide whether the Agency’s action in this matter regarding her IDGS services (community classes) was correct.

In the Appellant’s case, the evidence presented establishes that the ... classes met the criteria set out in the OPWDD Self-Direction Guidance above. The classes do not duplicate any other HCBS Waiver service as they are not explicitly offered instead of another waiver service, nor was there evidence presented that the timing of the classes was somehow indicative of a ‘day habilitation structure’ that meant the Appellant could not be approved for those classes due to the alleged similarity.