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3.0 Review Process for Decisions on Eligibility

Applicable to: Application Entities
Legislative Authority for Policy Directive:
Section 7(2) 2i
Effective Date:
August 15, 2013

Purpose

The purpose of this policy directive is to ensure that the process used by Application Entities to review a decision where an individual is deemed ineligible for Ministry-funded adult developmental services and supports adheres to the principles and objectives of equity, fairness, and provincial consistency.

The review process has three goals:

  1. To encourage review and resolution of decisions on eligibility at the local level;


  2. To provide timely resolution of disputes; and


  3. To provide a fair, unbiased and user-friendly review process.

This policy directive outlines the review process for individuals who are deemed ineligible for Ministry-funded adult developmental services and supports in accordance with the Act.

Policy

The Application Entity shall use a provincially-consistent review process to verify whether or not all relevant factors were considered in making the decision on eligibility and whether or not the decision rendered is fair, transparent, and consistent with the Act and Regulation.

At no stage of the review process is the accuracy or validity of the individual’s clinical diagnosis to be assessed or evaluated by the Application Entity.

Note: If an individual, and/or representative of their choice, believes that the diagnosis provided by a psychologist or psychological associate does not accurately reflect their level of cognitive and adaptive functioning, they must seek resolution of this issue with the psychologist or psychological associate who completed the psychological assessment/psychological report. Alternatively, the individual or person acting on their behalf may seek the second opinion of a psychologist or psychological associate registered with the College of Psychologists of Ontario and undergo additional diagnostic testing and/or assessment.

Directive

An Application Entity shall use a three-stage approach to review a decision on eligibility that is under dispute.

Stage 1

  • An individual requesting Ministry-funded adult developmental services and supports who is deemed ineligible in accordance with the Act may request a review of that decision.

  • The individual, and/or representative of their choice, has 25 business days from the date of the letter informing them of their ineligibility to provide the Application Entity with a written request for a review of that decision. The Application Entity may exercise discretion in extending this timeframe in instances where an individual, and/or representative of their choice, is unable to submit the written request as required.

  • Stage 1 of the review process will be conducted by the specific Application Entity staff who made the decision on eligibility based on the documents submitted by the individual in question, and the staff supervisor. The Application Entity must complete this stage within 15 business days of receiving the request to review the decision on eligibility.

  • At this stage of the review process, the Application Entity shall provide the individual and/or representative of their choice with:
    • a copy of the definition of a person with a developmental disability and eligibility criteria as set out in the Act and Regulation;
    • an opportunity to demonstrate that the eligibility criteria set out in the Act and Regulation have not been accurately applied in their case; and
    • an opportunity to provide any additional supporting information and documentation that may have a bearing on the eligibility decision.
  • The Application Entity staff and staff supervisor shall:
    • review the individual’s documentation, and any additional information or supporting documentation provided to the Application Entity, to confirm whether or not the individual meets the eligibility criteria in accordance with the Act and Regulation;
    • if requested, meet with the individual and/or representative of their choice to discuss the individual’s file and supporting documentation and to explain the eligibility criteria and how the criteria apply to their case; and
    • render a new decision on eligibility, and notify the individual and/or representative of their choice, in writing, of the outcome of the Stage 1 review, within 15 business days.

If the individual and/or representative of their choice disagrees with the outcome of their Stage 1 eligibility decision review by the Application Entity staff and staff supervisor, or believes that he/she was treated unfairly in the process, the individual may request a Stage 2 review.

Stage 2

  • Within 10 business days of receiving a decision on their Stage 1 eligibility decision review, the individual and/or representative of their choice may request in writing that the Executive Director of the Application Entity review the individual’s case. The Application Entity must then complete Stage 2 of the eligibility review within 15 business days of receiving the written request.
  • The Executive Director (or delegate) of the Application Entity shall:
    • determine if the rules in Stage 1 of the review were observed;
    • provide the individual and/or representative of their choice with an opportunity to submit any additional information and supporting documentation that may have a bearing on the review process and original eligibility decision;
    • review the individual’s information and supporting documentation to confirm whether or not the individual meets the eligibility criteria set out in the Act and Regulation; and
    • render a decision and notify the individual and/or representative of their choice, in writing, of the decision within 15 business days.
  • If the individual and/or representative of their choice disagrees with the outcome of their Stage 2 eligibility decision review by the Executive Director, or believes that he/she was treated unfairly in the process, the individual may request a Stage 3 review.

Stage 3

  • Within 10 business days of receiving a decision on their Stage 2 eligibility decision review, the individual and/or representative of their choice may request, in writing, a Stage 3 review by the Executive Director (or delegate) of an Application Entity in another region of the province.
  • The Application Entity that conducted the Stage 2 review shall send the written request for a Stage 3 review to the Executive Director (or delegate) of the Application Entity as determined by the individual requesting the review or, if the individual has no preference, by the Application Entity. The Executive Director of the Application Entity who receives this request for review must comply with the request and complete the Stage 3 eligibility review within 15 business days of receiving the written request.
  • The Application Entity that has deemed the individual ineligible at Stages 1 and 2 of the eligibility review process shall not participate in the Stage 3 review.
  • In the Stage 3 review process, the Executive Director (or delegate) of the Application Entity shall:
    • provide the individual and/or representative of their choice with the opportunity to provide any additional information and supporting documentation that may have a bearing on the review process and decision on eligibility.
    • determine if the rules in Stage 2 of the review were observed;
    • review the individual’s information and supporting documentation to confirm whether or not the individual meets the eligibility criteria set out in the Act and Regulation; and
    • render a Stage 3 review decision and notify the Application Entity that conducted the Stage 1 and Stage 2 reviews and the individual and/or representative of their choice of the decision rendered in writing.
    The decision of the Stage 3 review is final.