OPWDD Family Reimbursement Application

Allowable Items:

Recreation Activity/Program/Equipment

Integrated, community-based activity fees/supplies
Gym membership
Swim lessons
Instrumental and music lessons/fees (e.g., guitar lessons, piano lessons)
Soccer fees
Baseball
Braille bingo cards, playing cards and dominoes
Crafts
Equine therapy/Hippo therapy/Horseback riding
Karate/Tae Kwon Do lessons
Dance lessons
Cheerleading programs
Cooking classes (not resulting in certification)
Theatre classes/workshops
Museum membership
Bowling
Bean bag chair
Indoor swing
Mini trampoline (single user)
Climber
Fidget items/sensory toys
Shower head

Items/Services that are not covered or available through other means and are reviewed and approved by the committee:

Respite
Camp (see section G of the ADM)
Electronic devices (see section J of the ADM)
Supplements approved by a clinician and outlined in the individual’s treatment plan
Legal fees related to guardianship and special needs trusts
Clothing as a necessity or if there are specific needs related to the intellectual/developmental disability (IDD) (e.g., excessive chewing, destruction due to behavior or urination) as clinically indicated (i.e., included in the Life Plan or with other appropriate documentation requested by the DDRO); and
Other items as deemed appropriate and reimbursable by the DDRO.

Non-Allowable Items:

Items covered by Medicaid or healthcare insurer, including incontinence items
Items covered by other state paid benefits, including free cell phone programs
Furniture
Hotel/lodging, mileage and travel costs
Car fuel
Maintenance items
Items covered by self-direction budget, if someone is self-directing services
Diapers
Nutrisystem – weight loss program
Water fountain
Wipes
Battery for side-by-side bike
Dental activities
Enemas
Oral swabs, syringes
Appliances (washing machine, dryer)
Prescription eyeglasses
Rent deposit
Snowplow
Video monitoring system
Bed protector
Car repairs
Car seat
College courses/Certification programs
Cellular data for iPad
Conference expenses
Dermatology services
Disposable bib
Homeschool books
Life coach
Sedation
Home repairs
Personal training
Pool cover
Portable tub
Exercise equipment (eg: elliptical machine, treadmill)
Tutoring
Real property (e.g., home or apartment related costs)
Finance charges
Tax bills
Sales tax
Fines
Luxury items (e.g., swimming pools)
Concert tickets
Vehicles (e.g., cars, motorcycles)
Co-pays
Experimental treatments/therapies
CBD or marijuana products
Upgrades to services/items covered by HCBS Waiver or other sources, including self-direction budgets (e.g., upgrading fencing materials, additional funding for a higher cost camp)
Items and services that an individual is eligible for in the context of their educational services (e.g., occupational therapy, physical therapy)
Funeral expenses
Other items deemed not appropriate for reimbursement by the DDRO
GPS Trackers/devices
Regular and ongoing subscription plans
Academic testing/retesting
Items related to Waiver services (e.g. day program participation)

Please complete the form in full and have the relevant documentation to upload in order for your application to be considered.

Name Of Individual Receiving Services *

Email *

Phone *

Date of Birth *

Tabs No:

Address

Street Address

City

State

Country

Postal Code

Number of people in the home

Name of Parent / Relative / Guardian

Parent / Guardian Email:

Parent / Guardian Phone:

Care Manager's Name

Care Manager's Email

Care Manager's Phone

Care Manager's Address (Street/Zip/City)

Fiscal Intermediary (If Applicable - Name/Agency/Phone/Email):

What Is The Item(S) Or Service Requested For Reimbursement – Please Describe:

Please note - camp can only be reimbursed if the camp has a permit by the New York State Department of Health and/or Local Department of Health pursuant to Subpart 7 of the New York State Sanitary Code (see 10 NYCRR Subpart 7).

Is This Item/Service An Immediate Crisis Situation As Identified In The Guidelines? Please check one:

Yes

What Is The Total Amount Requested On This Application?

In USD

List all reimbursement applied for and/or received this contract year:

This information must be reported. Please be advised that $3,000 is the maximum total amount that may be reimbursed. If you have a large reimbursement request that exceeds an agency internal cap and you are submitting to multiple agencies for partial reimbursement, you must indicate this in the spaces below.

Required Documents

Notice of decision or other OPWDD eligibility document approved by DDRO (if current documentation is not on file with provider agency).

Signed application, receipts/invoice (photocopies and digital copies are acceptable), respite verification forms. (If receipt has been submitted to another agency for partial reimbursement, list what agency has the receipt.)

Clinical justification / letter from physician or clinician if the request is for a clinical item / service.

If enrolled in self-direction, a copy of the most recent self-direction expense report or budget which verifies that family reimbursement is accounted for.

If enrolled with a CCO, a copy of the most recent life plan with FSS family reimbursement properly documented.

How does this request directly relate to the individual’s disability?

In the event that a claim for goods or services is discovered to be fraudulent, the agency to which that reimbursement application was submitted is to be notified (if not the discovering entity) and will investigate the request in question and all documentation provided with the reimbursement request. In the event that the fraudulent claim is confirmed, the individual/family will be required to pay the amount reimbursed back to the agency (if the service/good was already reimbursed) and will be suspended from any future reimbursement for goods and services for a period of time determined by the agency and OPWDD. The recipient of the reimbursement may also be subject to legal actions as determined by the agency and OPWDD.

Families may submit requests for Reimbursement to the RO or a FSS Reimbursement provider agency at any time, depending upon which entity administers the reimbursement program in that region, using the form provided by the Family Reimbursement provider agency or obtained from the individual’s Care Manager or Care Coordinator. Funds are available only on a contract year basis. Any authorized, but unused, reimbursements may not be carried over by a receiving family from one year to the next. For self-directing individuals, verification is made to ensure that the FSS program is included in the current budget. Inclusion of funding in the budget does not guarantee that the request will be approved. Reimbursement requests must be consistent with FSS guidelines. Applications may be submitted to any of the Family Reimbursement Program providers by individuals, families, case managers or advocates. Anything submitted more than 90 days after purchase/occurrence will be awarded per the discretion of the Reimbursement Program provider. Applications that are not filled out in full will be returned, and payment will be delayed.

Please check:

I HAVE READ THE STATEMENT ABOVE AND UNDERSTAND THAT INFORMATION RELATED TO MY REQUEST FOR REIMBURSEMENT MAY BE MUTUALLY SHARED WITH AND/OR RECEIVED FROM OTHER AGENCIES WITHIN THE OPWDD REGION/DISTRICT.

Print Name of Parent / Guardian Signing Form *

Date Completed

Parent / Guardian Signature

Clear

Signed

If Submitted By Care Coordinator, Print Name:

Name of Care Coordination Organization (CCO)

Date Submitted