September 2017

1.2 Disability Adjudication Process

Summary of Policy

The DAU is responsible for determining if a person meets the legislative definition of a “person with a disability” under the ODSP Act.

A person with a disability is defined as a person who has a:

  • substantial physical or mental impairment that is continuous or recurrent and expected to last one year or more;
  • the direct and cumulative effect of the impairment results in substantial restrictions in one or more of the activities of daily living (i.e., the ability to attend to personal care, function in the community or function in a workplace); and
  • the impairment, its likely duration and restrictions have been verified by a prescribed health care professional.

An applicant must have an Application for Assistance Part 1 completed, and a referral made to the Disability Adjudication Unit (DAU) before being provided a Disability Determination Package (DDP).

The applicant has 90 days to complete and return the DDP to the DAU. If not submitted within 90 days, the application shall be determined withdrawn unless the DAU receives a written request for an extension from the applicant and approves a longer period of time.

Only prescribed health care professionals can complete the designated forms in the DDP.

Legislative Authority

Section 4(1), (2), 5(1) and 10(1) of the ODSP Act
Sections 4(1), 5(1), (2), 9, 12, 13, 14, 15, 16, 18, 46(1), (2) and 47 of the ODSP Regulation
Sections 38(2) and (3) of the Ontario Works Regulation
Section 13(1) and (5) of the Child and Family ServicesOntario Regulation 206/00

Summary of Directive

The Directive outlines:

  • how the DDP is to be completed
  • the roles and responsibilities of the DAU regarding the application process
  • the circumstances under which the applicant is exempt from the disability adjudication process
  • the application process for applicants under certain circumstances including:
    • applicants who are not yet 18 years of age;
    • applicants who reside in a lawful place of confinement; and
    • applicants who reside in a facility or hospital.

Intent of Policy

To describe the policy relating to the adjudication of applicants who apply as a person with a disability under the ODSP Act.

Application of Policy

Anyone has the right to make an application for ODSP if he/she believes him/herself to be a person with a disability as defined by subsection 4(1) of the ODSP Act.

An applicant for ODSP may apply through Ontario Works or an ODSP local office. Financial eligibility must be determined before an applicant for ODSP can be referred to the DAU. An applicant's financial eligibility is determined following the completion of the Application for Assistance Part 1 by Ontario Works or Ontario Disability Support Program staff.

Once financial eligibility is established, a referral must be made to the DAU by the Ontario Works or ODSP local office and the applicant is given a DDP.

It is the role of the DAU to make the determination of whether or not the applicant is “a person with a disability” under the ODSP Act, assign a medical review date if the person’s medical condition is likely to improve and respond to appeals related to a determination of disability.

Completion of the Disability Determination Package (DPP)

The DDP contains the approved application forms used to obtain verified information related to an applicant’s disability, medical condition(s), impairment(s), restriction(s) and likely duration.

The DDP is to be completed and returned to the DAU within the prescribed 90-days.

If an applicant encounters difficulty getting his or her DDP completed or submitted within the 90-day prescribed time frame, the person may contact the DAU directly and ask for an extension. An extension will be provided for extenuating circumstances such as hospitalization, detained in a lawful place of confinement or illness.

The DDP includes the following forms:

  • Health Status Report (HSR)
  • Activities of Daily Living Index (ADLI)
  • Self Report Form
  • Consent to the Release Medical Information
  • Instruction Sheet

Note: When providing the DDP, the applicant’s member identification (ID) is to be recorded on the HSR.

The DDP contains instructions for the applicant on the outside of the package, and a separate instruction sheet is also provided inside the DDP.

The instruction sheets provide direction on who can complete the HSR and the ADLI, as well as information on the importance of completing the Consent to Release Medical Information Form. It also contains information on completing the Self Report form, which the applicant or a designate can complete if they wish.

Instructions for health care professionals on how to complete the HSR and ADLI are found on the front page of the HSR and ADLI.
An envelope is provided with the DDP to submit the application directly to the DAU. Applicants should not submit the DDP through the Ontario Works or the ODSP local office.

The following prescribed health care professionals who are members of their respective regulatory college in Ontario may complete the HSR and/or ADLI:

Health Status Report (HSR)

  • Physician
  • Psychologist or Psychological Associate
  • Ophthalmologist or Optometrist
  • Registered Nurse in the Extended Class

Activities of Daily Living Index (ADLI)

  • Physician
  • Psychologist or Psychological Associate
  • Ophthalmologist or Optometrist
  • Registered Nurse in the Extended Class or Registered Nurse
  • Occupational Therapist or Physiotherapist
  • Audiologist or Speech Language Pathologist
  • Chiropractor
  • Social Worker

The Self Report form is optional, and can be completed by the applicant or a designate.

The DDP is only considered complete for adjudication when the HSR and ADLI is completed by the prescribed health care professional, the Consent to the Release Medical Information is complete, and the package is submitted in its entirety.

Applicants are encouraged to have their health care professional submit additional medical and supporting information with their application, e.g. specialist reports, psychological assessments, radiology reports, functional assessments etc.

The applicant is responsible for providing sufficient medical and supporting information to support his/her application. The DAU depends on this information to make an informed determination of whether or not an applicant is a person with a disability under the ODSP Act.

Applications Made through ODSP Offices

An applicant who is not in need of immediate financial assistance should apply for ODSP through the local ODSP office. ODSP staff are responsible for taking the initial application, and verifying and recording the information obtained from the applicant/trustee.

Once financial eligibility has been established a referral is made to the DAU and a DDP is provided to the applicant by the local ODSP office or Ontario Works office.

If the DAU determines that the applicant is a person with a disability, the DAU notifies the local office and the applicant of the decision. The local office is responsible for granting ODSP income support.

If the DAU determines that the applicant does not meet the definition of disability the DAU notifies the applicant and the referring office.

Applications Made through Ontario Works

Anyone wishing to apply for ODSP who is in immediate financial need can apply for financial assistance through Ontario Works. An applicant for ODSP applying through an Ontario Works office must first meet financial eligibility requirements.

Once financial eligibility has been established, a referral is made to the DAU and a DDP is provided to the applicant/participant.

If the DAU determines that the applicant is a person with a disability, the DAU notifies the Ontario Works office and the applicant of the decision. The Ontario Works office transfers the case to ODSP, and the local ODSP office is responsible for granting ODSP income support.

If the DAU determines that the applicant does not meet the definition of disability, the DAU notifies the applicant and the referring Ontario Works office.

Internal Review and Appeals

A determination that an applicant is not a person with a disability is an appealable decision.

The DAU is responsible for conducting the internal review, for providing written notice of the internal review decision and for filing a submission in response to a subsequent appeal to the Social Benefits Tribunal (SBT).

Role of the Disability Adjudication Unit (DAU)

The DAU is a centralized unit that comprises various ministry staff, including Case Presenting Officers (CPOs) and Disability Determination Adjudicators.

The DAU is responsible for determining if a person meets the legislative definition of a “person with a disability” under the ODSP Act, and for determining whether or not a medical review date should be assigned.

A medical review date is to be assigned unless there is no likelihood of improvement in the applicant’s medical condition. For conditions that may improve, a medical review date is assigned for a date of two or five years.

The decision to assign a medical review date cannot be appealed to the SBT. The SBT does not have the authority to hear appeals about setting a medical review date.

Recipients are informed at the time of being found to be a person with a disability if a medical review date has been assigned. In such cases and at the appropriate time, the DAU will notify the recipient that a medical review is now required and provide the recipient with a medical review DDP. The DAU conducts the medical review. Please see Directive 2.9 Medical Reviews .

Exemptions from the Disability Adjudication Process

Applicants who are members of a prescribed class do not require disability adjudication and are granted ODSP income support if they are found to be financially eligible.

Members of a prescribed class include:

  • A person in receipt of federal Canada Pension Plan Disability Benefits (CPP-D);
  • A person in receipt of Quebec Pension Plan Disability Benefits (QPP-D);
  • A person aged 65 or over and not eligible for Old Age Security;
  • A person who on May 31, 1998 was a recipient or spouse of a recipient of benefits under specific case classes under FBA; or
  • A former resident of a Schedule 1 facility under the Developmental Services Act (DSA) who ceased to be resident of that facility on or after June 1, 1998. Note: the Schedule 1 facilities under the DSA include Huronia Regional Centre (Orillia), Rideau Regional Centre (Smiths Falls) and South Western Regional Centre (Blenheim).
  • A person who is already determined eligible for services, supports and funding under the Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act, 2008 (SIPDDA). This includes:
    • persons living in the community as a renter, owner, a tenant or a border
    • persons living in an intensive support or supported group living residence as defined under the SIPDDA

The following are also members of a prescribed class but only while residing in the institutions listed:

  • A person residing in a facility that was a former Provincial Psychiatric Hospital (PPH), the Centre for Addiction and Mental Health, or Homewood Health Centre;
  • A person residing in a home under the Homes for Special Care Act.

When a recipient ceases to be a member of a prescribed class, for example, ineligible for CPP-D or QPP-D, or becomes eligible for OAS, they are required to submit a DDP and a determination must be made of whether he/she is a person with a disability under the ODSP Act. The person must meet all the eligibility requirements to be eligible for ODSP income support.

If a former ODSP recipient qualifies for rapid reinstatement, they are not required to go through the disability adjudication process. However, they must qualify financially and meet all other eligibility requirements for ODSP. All other ODSP applicants must be referred to the DAU and determined to be a person with a disability before being granted ODSP income support.

Applicants Previously Found to be a Person With a Disability But Not Granted ODSP Income Support

Applicants who were adjudicated and found to be a person with a disability, but did not meet all of the financial and eligibility rules and, as a result, were never granted ODSP income support, do not need to be re-adjudicated if they reapply for ODSP.

A determination of disability made in relation to a previous ODSP application can be used for the purpose of a new application.

If the original disability determination included a medical review, a medical review would be required as follows:

  • If the person reapplies before the medical review date, the medical review would occur on the date set at time of original application/disability determination.
  • If the person reapplies after the medical review date, the medical review would occur at a future date determined by the Director.

Application Process in Exceptional Situations

Applicants Who Are Turning 18 Years of Age

An Application for Assistance Part 1 should be taken to determine financial eligibility 6 months prior to an applicant’s 18th birthday. Once financial eligibility is established, the applicant is given the DDP to complete and submit to the DAU. In addition, local office staff need to ensure that a referral is made to the DAU when the DDP is provided to the individual. While the application can be adjudicated, the earliest that a person can be granted ODSP is on their 18th birthday provided that all other eligibility criteria are met.

Children who are in receipt of Assistance for Children with Severe Disabilities (ACSD) may be eligible for ODSP and may apply 6 months prior to their 18th birthday.

Applicants Who Are Eligible to Receive Continued Care and Support for Youth From a Children’s Aid Society

Youth in Children’s Aid Society’s (CAS) care who are approaching the age of 18 may apply for ODSP 6 months before their 18th birthday.

Youth who are in receipt of Continued Care and Support for Youth (CCSY) (formerly Extended Care and Maintenance) may be eligible for ODSP and may also apply. CCSY is a support service provided by CASs to eligible youth who require financial and/or other supports beyond their 18th birthday in order to successfully complete the transition to independent living or to achieve transfer to an appropriate adult program. Under the Child and Family Services Act and Ontario Regulation 206/00, CCSY payments for financial support must stop when ODSP commences.

CCSY payments are often provided to youth at the beginning of the month. ODSP is provided at the end of the month.

To facilitate a smooth transition from CCSY to ODSP and to avoid a lapse in funding, CASs have the flexibility to provide additional financial supports as part of a youth’s CCSY payment in the last month of his or her eligibility for CCSY financial support. The decision to increase this final payment rests with the individual CAS.

ODSP staff are to confirm the exact amount of the financial support by contacting the local CAS and advising the CAS of the youth’s grant date so that CCSY payments may be discontinued once ODSP is granted.

Note that the CAS may continue to provide non-financial CCSY support to an individual on an as needed basis. Examples of non-financial support include but is not limited to indirect payments for day treatment, therapy, support services, bus passes, etc.As these indirect payments for support services are voluntary on the part of the CAS, they are not to be treated as income for ODSP purposes. Please refer to Directive 5.8 - Gifts and Voluntary Payments for further information on voluntary payments.

If a case is to be granted retroactively, the CCSY financial support payment that was received during the retroactive period is to be charged as income and deducted. As ODSP rates are generally higher than CCSY financial support payments, this will likely result in ODSP arrears owing to the applicant. However, it should be noted that there may not be any ODSP eligibility during the last month that CCSY is issued, depending on the amount of CCSY that has been provided by the local CAS. See example below which assumes that the applicant was receiving a monthly CCSY financial support payment of $850, received a double CCSY payment in the month of ODSP grant, and is eligible for $ 1151 per month from ODSP.

Treatment of Continued Care and Support for Youth (CCSY) Income
At Time of ODSP Grant (Retroactive)

CCSY Applicant Requiring Adjudication:

ODSP completes the Application Part 1. All required information Received:

September 3, 2017

Financial Eligibility Determined and DDP provided:

September 9, 2017

DAU receives completed DDP:

October 30, 2017

DAU determines applicant to be a person with a disability:

 January 3, 2018

The date of grant is the first day of the month following the date the application was completed: Date of grant is November 1, 2017.

Month

ODSP Monthly Maximum

CCSY Monthly Payment Received

ODSP Entitlement (Arrears Owing)

November 2017

$ 1151 -

$850 =

$301

December 2017

$ 1151 -

$850 =

$301

January 2018

$ 1151 -

$1700 (double CCSY Payment) =

$0.00 (no eligibility as CCSY income
precludes)

February 2018

$ 1151 -

$0.00 =

$ 1151
(first full ODSP cheque)

CCSY terminated in March, after the double payment was issued, as ODSP commenced.

Applicants in a Lawful Place of Confinement

Persons who are in a lawful place of confinement are not eligible for income support.

However, to facilitate a smooth transition to the community, the DAU provides DDPs directly to correctional facilities. Where appropriate, correctional facility physicians or other approved health care professionals can complete the DDP and return it to the DAU. Local offices should not provide DDPs if requested by a provincial or federal correctional facility, by an advocate or individual in a facility; they are to be directed to contact the DAU.

Ontario Works and ODSP staff should not complete an Application Part 1 for a person detained in custody. The individual is provided with direction from the correctional facility once he or she is released to contact either the Ontario Works Intake Screening Unit or the ODSP local office to have financial eligibility established.

An electronic referral must be made to the DAU by the Ontario Works or ODSP office for persons who are financially eligible. The DDP is only adjudicated by the DAU once financial eligibility has been determined by Ontario Works or ODSP local office upon the person’s release.

Residents of a Former PPH, Divested Psychiatric Hospitals, Institutions Under the Developmental Services Act and Homes Under the Homes for Special Care Act

People residing in a former PPH, divested psychiatric hospital, institution under the Developmental Services Act, and a home under the Homes for Special Care Act are members of a prescribed class.

However, upon being discharged from the facility, they cease to be members of a prescribed class unless they qualify as a member of a prescribed class for other reasons (e.g. in receipt of CPP-D). Residents leaving the facility who no longer qualify as a member of a prescribed class must be adjudicated.

For this reason, at the time of the initial application, intake staff should attempt to determine the anticipated length of the applicant’s stay in the institution.

ODSP staff should facilitate discussions with the applicant or their advocate and/or institution staff to determine if and when a referral to the DAU should be made.

In some cases, it may be appropriate to make the referral to the DAU at the time of the initial application. In other cases, it may be more appropriate to wait until a discharge plan is in place. However, a referral to the DAU is not contingent upon a discharge plan being in place.

A resident who will cease to be of a prescribed class can apply as follows:

  • If a person has not completed an Application for Assistance Part 1 within the last year, the Application: Part 1 must be taken to determine financial eligibility. Once financial eligibility is established, the applicant is provided with a DDP to complete and submit to the DAU.
  • If a person has completed an Application: Part 1 within the past year, and financial eligibility has been established, the applicant can be provided a DDP. The DDP can be completed and submitted prior to the resident being discharged from the facility.

Applicants Who Are in Hospital

Applicants temporarily residing in a hospital, psychiatric facility, or a substance abuse recovery home (SARH) may be eligible for income support. The budgetary requirements are calculated in accordance with Section 6 of the Directives. Once the budgetary requirements have been determined, please see Directive 8.2 Budgetary Requirements for Recipients/Dependants Temporarily in a Hospital, Psychiatric Facility, or Substance Abuse Recovery Home for related policy.

Re-applications to ODSP:

If an applicant has been determined to be “not a person with a disability”, they may reapply for ODSP at a later date if there has been a change in their circumstances, for example if there has been an aggravation of the applicant’s medical condition or a new medical condition.

Related Directives:

1.1 Applications
1.3 Rapid Reinstatement
1.4 Date of Grant
2.2 Who is Eligible: Dependent Children
2.9 Medical Reviews
6.1 Basic Needs Calculation
6.2 Shelter Calculation
6.3 Board and Lodge
6.4 Special Diet Allowance
7.1 Extension of Income Support
8.1 Budgetary Requirements for Recipients who Reside in Institutions
13.1 Notice of Decision and Internal Review
13.2 Appeals