Developmental Disabilities Program: Eligibility Carla Rime, Eligibility Specialist

Developmental Disabilities Program: Eligibility Carla Rime, Eligibility Specialist

Developmental Disabilities Program: Eligibility Carla Rime, Eligibility Specialist (406) 444-6047 [email protected] Overview Montana State Definition of Developmental Disabilities Eligibility Applications Requirements Per Rule Supplemental Information Secure Submission and Determination Notification Guidelines in Making Determinations Eligibility: General Eligibility Requirements Rule

0208 Medicaid Home and Community-Based Services Program: Eligibility Rule Checklist for Developmental Disabilities Services (DDS) Eligibility Criteria by William Cook, Ph.D. 0208 Medicaid Home and Community-Based Services Waiting List Montana State Definition of Developmental Disabilities Developmental disabilities means disabilities attributable to intellectual disability, cerebral palsy, epilepsy, autism, or any other neurologically disabling condition closely related to intellectual disability and requiring treatment similar to that required by intellectually disabled individuals if the disability originated before the person attained age 18, has continued or can be

expected to continue indefinitely, and results in the person having a substantial disability. MCA 53-20-202(3) Eligibility Applications: Requirements Per Rule The following documents must be submitted to the departments eligibility specialist to make a determination of eligibility for acceptance into the 0208 HCBS Waiver Program: (a) a Vineland II; (b) a current psychological evaluation, that for adults, is no more than ten years old; and (c) page one of the eligibility determination form.* * Please complete and submit the most updated version from 11/01/2013 Eligibility Applications: Requirements Per Rule

Page one of the Eligibility Determination Form 11/01/2013 State of Montana Eligibility Determination Form for Developmental Disabilities Services (Children Age 6-15) Applicant: Date of Birth: Date Form Completed: Social Security #: Form Completed By: Parent/Family Contact: [Address] Chronological Age:

Assigned Case Manager: [Phone #] PART 1: Background Information A. Summarize Historical Data (NK = not known, NR = not relevant, give date and all past diagnoses that have been received in each area): 1. 2. 3. 4. 5. 6. 7. B. Developmental History: Medical History: Educational History: Social History:

Mental Health History: Previous Services Received: Past Test Results (note if different from current findings): Review of Current Status and Needs: 1. Current residential placement and needs: 2. Current school placement and needs: 3. Other current needs or special problems (social, emotional, medical, legal, case-management, etc.): Eligibility Applications: Requirements by Rule Psychological Evaluation The Psychological Evaluation with IQ testing should be provided in its entirety. A couple of pages from an evaluation or a summary of scores on a school report is generally not sufficient. If an applicant is untestable, a statement from a psychologist

stating as such needs to be provided, as well as information on alternative testing/observations (refer to Determining Eligibility for Services to Persons With Developmental Disabilities in Montana: A Staff Reference Manual (6th Edition-2013), Appendix K). A recent assessment for adults is generally one that has been conducted within 3 years. A recent assessment for younger children is generally one that has been conducted within 1-2 years (refer to Determining Eligibility for Services to Persons With Developmental Disabilities in Montana: A Staff Reference Manual (6th Edition-2013), Chapter 9). Eligibility Applications: Requirements by Rule Vineland-II Survey Interview Form Parent/Caregiver Rating Form Teacher Rating Form

Expanded Interview Form Maladaptive Behavior Index Average Elevated Clinically Significant Eligibility Applications: Supplemental Information Previous psychological evaluations School reports (i.e., IEP, CST, Evaluation Report, etc.) Medical or psychiatric documentation

pertaining to any diagnoses Although the supplemental information is not a requirement, it is helpful in making a determination. If it has not already been submitted, I may request this additional information in cases that are close-to-call. Eligibility Applications: Supplemental Information Examples of close-to-call cases IQ and/or adaptive scores around 70 Statistically significant differences between IQ subscales of 15+ points Full

Inconsistencies between IQ, adaptive, and achievement scores Full Scale IQ is then interpreted with caution Scale IQ of 65 and an Adaptive Behavior Composite of 85 Inconsistent IQ scores over time IQ scores above and below 70 The validity of the results are in question and may not reflect the persons true potential Difficult Diagnoses

Mental Health Diagnoses (ADHD, RAD, PTSD, ODD, Schizophrenia, etc.) Autism Spectrum Disorder (Pervasive Developmental Disorder NOS, Aspergers) Fetal Alcohol Spectrum Disorder (FAE, FAS, ARND) Cognitive Disorder NOS Other neurological conditions, probable, provisional, or rule-out diagnoses Eligibility Applications: Supplemental Information In some cases, an updated psychological evaluation will be requested before a determination is made Determining

Eligibility for Services to Persons With Developmental Disabilities in Montana: A Staff Reference Manual (6th Edition-2013) Appendix I: Operational Eligibility Criteria for Montana Developmental Disabilities Services (DDS) Appendix J: Requirements for Psychological Evaluation Reports Utilized by the Montana Developmental Disabilities Program (DDP) for Making Eligibility Decisions Eligibility Applications: Secure Electronic Submission and Determination Notification Secure Electronic Submission Therap Scomm

State of Montana File Transfer Service https://transfer.mt.gov Determination Notification Determination letter mailed to individual or family/ guardian Electronic copy of the letter to the person who submitted the request Electronic copy of the letter to the Regional Administrative Assistant File Guidelines in Making Determinations Eligibility:

General Eligibility Requirements Rule http://www.mtrules.org/gateway/ruleno.asp?RN=37%2E34%2E201 0208 Medicaid Home and Community-Based Services Program: Eligibility Rule http://www.mtrules.org/gateway/ruleno.asp?RN=37%2E34%2E906 Determining Eligibility for Services to Persons With Developmental Disabilities in Montana: A Staff Reference Manual (6th Edition-2013) by William Cook, Ph.D.

http:// www.dphhs.mt.gov/Portals/85/dsd/documents/DDP/Home%20Page/ EligibilityReferenceManual.pdf The Developmental Disabilities Policy http://www.dphhs.mt.gov/dsd/DevelopmentalDisabililities/ DDPpolproced.aspx Eligibility: General Eligibility Requirements Rule: 37.34.201 (1) A person, in order to be considered for placement into a developmental disabilities services program funded through the Developmental Disabilities Program (DDP) of the department, must be determined by the

department in accordance with the criteria of this rule to be a person with a developmental disability. (2) The Determining Eligibility for Services to Persons with Developmental Disabilities in Montana: A Staff Reference Manual, 6th Edition, 2013, sets forth the requirements for eligibility Eligibility: General Eligibility Requirements Rule: 37.34.201 (3) Eligibility for the DDP service programs, with the exception of federally funded Part C services, must be determined in accordance with the requirements of the Determining Eligibility for Services to Persons with Developmental Disabilities in Montana: A Staff Reference Manual, 6th Edition, 2013. A copy of the manual may be obtained from the Department of Public Health and Human Services, Developmental Services Division, Developmental Disabilities Program, 111 N. Sanders, P.O. Box 4210, Helena,

MT 59604 or at http://www.dphhs.mt.gov/dsd/ddp/ EligibilityReferenceManual.pdf 0208 Medicaid Home and Community-Based Services Program: Eligibility Rule: 37.34.906 (1) A determination that a person is eligible to be considered for acceptance into the Medicaid Home and Community-Based Services (HCBS) Waiver Program does not entitle a person to selection and entry into the HCBS Waiver Program (2) A person is eligible to be considered for acceptance into the Medicaid HCBS Waiver Program if the person: (a) is determined by the Developmental Disabilities Program (DDP) to be a person with a developmental disability in accordance with the criteria specified and approved in the waiver from the Centers for Medicare and Medicaid Services and in accordance with Title 37, chapter 34, subchapter 2; (b) applies for and meets the applicable Medicaid financial eligibility requirements found in ARM Title 37, chapter 82; and

(c) requires the level of care provided in an intermediate care facility for individuals with intellectual disability (ICF/IID), as determined by the DDP 0208 Medicaid Home and Community-Based Services Program: Eligibility Rule: 37.34.906 (3) The level of care of an ICF/IID is needed when a person who is intellectually disabled: (a) has severe medical problems requiring substantial care, but not to the extent that habilitation is impossible; (b) has extreme deficits in self-care and daily living skills which require intensive training; (c) has significant maladaptive social and/or interpersonal behavior patterns which require an ongoing, supervised program of intervention; or (d) has specialized service needs, and exhibits physical or mental limitations or changes similar to those expected in an older person.

0208 Medicaid Home and Community-Based Services Program: Eligibility Rule: 37.34.906 (4) A person who has been admitted to an ICF/IDD and who is discharged to enter services under the 0208 Medicaid HCBS Waiver Program for persons with developmental disabilities is considered to be of the level of care of an ICF/IDD and need not be evaluated as provided in (2). (5) For a person through the age of seven, the eligibility review panel (ERP) must make the determination of eligibility. 0208 Medicaid Home and Community-Based Services Program: Eligibility Rule: 37.34.906

(6) The ERP must consist of the following members (a) a waiver-funded childrens case manager; (b) a providers administrator or supervisor; (c) a departments quality improvement specialist; (d) a staff person who has had recent contact with the child, if applicable; and (e) other members as determined by the panel, if applicable. 0208 Medicaid Home and Community-Based Services Program: Eligibility Rule: 37.34.906 (7) The waiver-funded childrens case manager must submit the following to the ERP for a determination of eligibility: (a) a diagnostic statement from a physician; and (b) any testing that reflects developmental delays; or

(c) a Vineland II (adaptive functioning assessment); (d) a current psychological evaluation; and (e) the eligibility determination form for children. (8) For eligibility determinations made by the ERP, The Determining Eligibility for Services to Persons with Developmental Disabilities in Montana: A Staff Reference Manual does not apply to an eligibility determination for a child up to age seven. 0208 Medicaid Home and Community-Based Services Program: Eligibility Rule: 37.34.906 (9) The ERP may determine a child is eligible if: (a) the child has a diagnosis of physical or mental condition that has a high probability of resulting in a developmental disability; or (b) the child is experiencing developmental delays, with a 50% delay in one of the following areas or a 25% delay in two or more of the following areas:

(i) cognitive development; (ii) physical developments, including vision and hearing; (iii) speech and language development; (iv) social and emotional development; or (v) self-help skills. 0208 Medicaid Home and Community-Based Services Program: Eligibility Rule: 37.34.906 (10) The department designee must annually administer a level of care re-determination. (11) A child who has previously been determined eligible for services by the ERP must have a determination of eligibility by the departments eligibility specialist prior to the childs eighth birthday. (12) For a person age eight and older, the department must make a determination of eligibility for consideration of acceptance into the 0208 HCBS

Waiver Program. (13)The department may make a determination of eligibility for acceptance into the 0208 HCBS Waiver Program as early as the age of six. 0208 Medicaid Home and Community-Based Services Program: Eligibility Rule: 37.34.906 (14) The following documents must be submitted to the departments eligibility specialist to make a determination of eligibility for acceptance into the 0208 HCBS Waiver Program: (a) a Vineland II; (b) a current psychological evaluation, that for adults, is no more than ten years old; and (c) page one of the eligibility determination form.

0208 Medicaid Home and Community-Based Services Program: Eligibility Rule: 37.34.906 (15) The Determining Eligibility for Services to Persons with Developmental Disabilities in Montana: A Staff Reference Manual, as adopted in ARM 37.34.201, sets forth the requirements for eligibility of the DDPs service programs. (16) Upon a determination of ineligibility, if the person is: (a) on the waiting list, his or her name will be removed from the waiting list; or (b) currently in waiver services, he or she will be exited from the 0208 HCBS Waiver Program ten days from the date of the Checklist for Developmental Disabilities Services (DDS) Eligibility Criteria by William Cook, Ph.D.

A Full Scale IQ score of 70 or below (Rationale needed for scores over 70) Adaptive Behavior Composite Score of 70 or below (Again-provide rationale if higher) Significant functional limitations in 3 or more life activities (self-care, receptive and expressive language, learning, mobility, selfdirection, capacity for independent living, economic self-sufficiency) Checklist for Developmental Disabilities Services (DDS) Eligibility Criteria by William Cook, Ph.D. Documentation that the developmental disability occurred before age 18 Statement that the developmental disability

has continued or can be expected to continue indefinitely Statement that the person needs treatment required by intellectually disabled individuals (special, interdisciplinary, or generic care, treatment, or other services which are of lifelong or extended duration and are individually planned and coordinated) Checklist for Developmental Disabilities Services (DDS) Eligibility Criteria by William Cook, Ph.D. For autism spectrum disorders, the person must meet level 2 or level 3 severity guidelines in DSM-5 and demonstrate significant impairment of intellectual functioning that is similar to an intellectual disability and requires similar treatment

For epilepsy , cerebral palsy, or any other neurological condition, the person must still demonstrate a significant impairment of intellectual functioning that is similar to an intellectual disability and requires similar treatment Checklist for Developmental Disabilities Services (DDS) Eligibility Criteria by William Cook, Ph.D. A person with an apparent combination of developmental disabilities and mental illness diagnoses may be determined to be eligible for developmental disability services if either number 1 or 2 below are satisfied: 1.

The validity section of the person's psychological evaluation report definitively states that the obtained test results were not significantly impacted by behaviors associated with the person's mental disorder (e.g., inattention, lack of motivation, disruptive behaviors, etc.). 2. If a person with a mental disorder in an appeals process is referred for an independent psychological evaluation, then the psychologist should be specifically asked whether or not the mental illness affected the intelligence test scores and to what extent. 0208 Medicaid Home and Community-Based Services Waiting List Effective July 1, 2015 I will be placing individuals who have been determined DD eligible on the 0208 statewide

waiting list A new 0208 Waiting List Entry/Change Form is being developed Summary Montana State Definition of Developmental Disabilities Eligibility Applications Requirements Per Rule Supplemental Information Secure Submission and Determination Notification Guidelines in Making Determinations Eligibility: General Eligibility Requirements Rule 0208 Medicaid Home and Community-Based Services

Program: Eligibility Rule Checklist for Developmental Disabilities Services (DDS) Eligibility Criteria by William Cook, Ph.D. 0208 Medicaid Home and Community-Based Services Waiting List Questions/Concerns

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