Notice of Decision (NOD)
A Notice of Decision (NOD) is a written document that notifies an applicant/participant of an action being taken by the waiver program, including an explanation of the reasons for the action.
The RRDS is responsible for assuring the correct NOD is completed and sent out to each applicant/participant, Legal Guardian (if applicable), Authorized Representative (if applicable), Service Coordinator, NHTD Waiver Management staff, and LDSS as specified on the bottom of each form.
The Service Coordinator provides follow-up in this process by contacting the applicant/participant to discuss the reasons for the NOD and to assure his/her understanding of the right to request an Informal Conference and/or Fair Hearing (with aid continuing, if appropriate).
Types of Notice of Decision Forms
The following describes each type of Notice of Decision form used in the NHTD waiver program (refer to Appendix B – forms NOD.1 to NOD.9):
- Authorization is sent to an applicant when he/she has been approved to participate in the waiver program. This NOD includes the effective date of services. When a participant is authorized for the NHTD waiver he/she is entered into WMS until a NOD is provided to LDSS indicating the individual is no longer a participant.
- Denial of Waiver Program is sent when an applicant will not become a NHTD waiver participant for the following reasons:
- The applicant chooses not to receive waiver services;
- The applicant is not:
- assessed to require a nursing home level of care based on the PRI/SCREEN;
- 18 years of age or older;
- in possession of appropriate documentation verifying a physical disability, if under age 65; or
- capable of living in the community with the assistance of informal supports, non-Medicaid supports, State Plan Medicaid services, and/or waiver services.
- The services and supports available through the waiver and all other sources are not sufficient to maintain the individual's health and welfare in the community;
- The applicant chooses to receive services from another Home and Community Based Services Medicaid Waiver or State Plan Services
- The cost of the Service Plan is above the level necessary to meet the federally mandated requirement that waiver services must be cost neutral in the aggregate when compared to Statewide nursing home costs;
- The applicant is not in need of one or more waiver services; and/or
- The applicant is not Medicaid eligible. When an applicant/participant is denied for this reason, a notice of denial is sent to the applicant/participant by LDSS. The process for pursuing a Fair Hearing regarding their determination may be pursued through the Fair Hearing process as identified in the Notice of Decision received by the /applicant/participant from LDSS system.
- Intent to Discontinue From the Waiver Program (1) is sent to a participant when he/she chooses to no longer participate in the waiver program.
- Intent to Discontinue From the Waiver Program (2) is sent to a participant when the following occurs:
- (a) The participant is no longer eligible for a nursing home level of care, per PRI and SCREEN;
- Waiver Services cannot safely maintain the participant in the community;
- An agreement can not be reached between participant and waiver entities regarding the Service Plan;
- The participant no longer needs waiver services to assure health and welfare in the community;
- Other appropriate reason as documented on the form.
- Reduction and/or Discontinuation of Waiver Service(s) is sent to a participant when there is a reduction in the hours/frequency of a waiver service(s) and/or discontinuation of waiver service(s).
- Denial Of A Waiver Provider/Denial Of A Waiver Service is sent to a participant when his/her request for a particular waiver provider or a request for an additional service(s) is denied by the RRDS.
Note: When a request for a particular provider is denied by the RRDS because the agency is under Vendor Hold status and therefore can not accept any new participants, an NOD is not issued by the RRDS.
Additionally, when it is the waiver provider agency who is unable/unwilling to accept a participant, an NOD is not issued to the participant.
- Addition and/or increase of Waiver Service(s) is sent to a participant when there is an increase in the hours/frequency of a waiver service(s) and/or when a new waiver services is added to a participant's Service Plan.
- Suspension is sent when all waiver services are being held due to the participant's temporary absence from participation in the NHTD waiver (e.g. travel in/out of NYS, hospitalization or nursing home placement, incarceration, etc). The Service Coordinator is responsible for distributing this Notice to all waiver providers. A suspension 'holds' a participant's place in the NHTD waiver for up to thirty (30) calendar days at which time the participant's situation is re-evaluated by the Service Coordinator. If additional time is deemed appropriate by the Service Coordinator and RRDS, the Suspension can be extended for up to an additional thirty (30) calendar days.
Upon resuming waiver services following a period of suspension, the RRDS issues written notification to the participant that the suspension has been cancelled. The Service Coordinator must determine whether the participant is in need of an Addendum or a Revised Service Plan and provide timely follow up.
If the participant is unable to resume participation in the waiver by the end of the suspension period, the RRDS issues an NOD-Discontinuation from Waiver Program to the participant.
- Notification of Death of a Waiver Participant to Local Department of Social Services is sent when a participant has died.
Note: This notice is not sent to the participant's home, legal guardian, or to any family/designated representatives. It is only intended for the Service Coordinator, NHTD Waiver Management staff and LDSS in county of residence and with fiscal responsibility as noted on the bottom of the form.