SCOPE:

Administrative Entity Administrators or Directors

County Mental Health/ID Program Administrators or Directors

Supports Coordination Organization Directors

County Assistance Office Executive Directors

Individuals and Families

PURPOSE:

The purpose of this bulletin is to issue policy and procedures for the initial evaluation and annual re-evaluation of an individual’s eligibility for services and supports provided under the Consolidated and P/FDS Waivers supporting individuals with an intellectual disability, autism spectrum disorder, and children age 8 and under with a developmental disability diagnosis.

BACKGROUND:

Prior to July 1, 2017, the eligibility for the Consolidated and P/FDS Waivers was restricted to people 3 years of age or older with a diagnosis of intellectual disability who met the level of care criteria for an intermediate care facility for individuals with an intellectual disability (ICF/ID). Beginning July 1, 2017, the Department has expanded eligibility in the Consolidated and the P/FDS Waiver to include individuals of any age with an intellectual disability or autism spectrum disorder, and children age 8 and under with a developmental disability diagnosis. To be eligible for the waivers, individuals with these diagnoses must meet the level of care requirements for either the ICF/ID or intermediate care facilities for persons with other related conditions (ICF/ORC). As a condition of Federal Financial Participation (FFP), individuals receiving services under a Medicaid Waiver authorized under 1915(c) of the Social Security Act must satisfy level of care and financial eligibility requirements. These requirements are in accordance with state assurances established in federal regulations and the Department's approved Waivers.

DISCUSSION:

This bulletin applies to eligibility determinations for Consolidated and P/FDS Waiver services for an individual as well as re-evaluations issued on and after the effective date of this bulletin. This bulletin clarifies procedures to evaluate whether individuals with an intellectual disability, autism spectrum disorder, and children age 8 and under with a developmental disability diagnosis are eligible to receive state and federal funding for the provision of services under the Consolidated and P/FDS Waivers. These procedures apply to responsibilities carried out by Administrative Entities (AEs), County Mental Health and Intellectual Disabilities (MH/ID) Programs, and County Assistance Offices (CAOs).

This bulletin does not affect eligibility criteria procedures for services provided in ICFs/ID which are contained in 55 Pa. Code Chapter 6210 and Bulletin 00-02-13, Need for ICF/ID Level of Care[1]. This bulletin does not affect eligibility criteria procedures for services provided in ICFs/ORC which are contained in 55 Pa. Code Chapter 6210. Eligibility determinations for county Mental Health/Intellectual Disability (MH/ID) program services should continue to be conducted in accordance with ODP Bulletin 4210-02-05, Clarifying Eligibility for Intellectual Disability Services and Supports1.

POLICY:

Level of Care Requirements

To be eligible for enrollment into the Consolidated or P/FDS Waiver, an individual must meet level of care requirements for either ICF/ID or ICF/ORC requirements as described below.

The Initial Level of Care processes described in Section 1 below are to be used both to screen for eligibility, prior to offering service delivery preference, and for verification of level of care needs prior to enrollment in the Consolidated or P/FDS Waiver when waiver capacity becomes available. The re-evaluation process described in Section 2 below is only to be used to determine continued eligibility for the Consolidated or P/FDS Waiver after enrollment in the Waiver.

Section 1: Initial Level of Care

  1. Initial ICF/ID Level of Care Evaluation

There are four fundamental criteria that must be met prior to an individual being determined eligible for an ICF/ID level of care:

1.The individual must have a diagnosis of intellectual disability,

2.The individual must have adaptive skill deficits in three or more areas based on a standardized adaptive functioning test,

3.The intellectual disability must have occurred prior to age 22, and

4.The individual must be recommended for an ICF/ID level of care based on a medical evaluation.

The AE shall request documentation of the diagnosis of intellectual disability during the screening for general eligibility and registration process. The following criteria must be met to document a diagnosis of intellectual disability and ICF/ID level of care:

1.A licensed psychologist, certified school psychologist, psychiatrist, developmental pediatrician, or licensed physician who practices psychiatry certifies that the individual has significantly sub-average intellectual functioning which is documented by either:

  • Performance that is more than two standard deviations below the mean of a standardized general intelligence test, which reflects a Full Scale score of 70 or below including Verbal and Performance scores of 70 or below; or
  • Performance that is slightly above two standard deviations below the mean of a standardized general intelligence test during a period when the individual manifests serious impairments of adaptive behavior.

2.A Qualified Developmental Disability Professional (QDDP) who meets criteria established in 42 CFR 483.430(a) and the approved Consolidated and P/FDS Waivers certifies that the individual has impairments in adaptive behavior based on the results of a standardized assessment of adaptive functioning[2] which shows that the individual has substantial functional limitation in three or more of the following areas of major life activity:

  • self-care,
  • receptive and expressive language,
  • learning,
  • mobility,
  • self-direction,
  • capacity for independent living.

3.Documentation substantiates that the individual has had these conditions of intellectual and adaptive functioning manifested during the developmental period which is from birth up to the individual’s 22nd birthday.[3]

4.Documentation of the medical evaluation may be either an examination performed by a licensed physician, physician's assistant, or nurse practitioner that states the individual is recommended for ICF/ID level of care or a Form MA 51 completed by a licensed physician, physician's assistant, or nurse practitioner.

Documentation of the results of both the standardized general intelligence test and the standardized assessment of adaptive functioning shall consist of all of the following:

  • The clinical data and an overall score.
  • Documentation from the certifying practitioner that the results are considered valid and consistent with the individual’s functional limitations.
  • A statement by the certifying practitioner as to whether the results indicate that the individual has an intellectual disability.

If the individual does not have documentation of a standardized general intelligence test and/or a standardized assessment of adaptive functioning, the AE will assist the individual in obtaining the necessary test and/or assessment. If it is unclear with existing documentation whether an individual has substantial functional limitation in three or more areas of major life activity, the AE will assist the individual in obtaining a secondary review. If necessary, the Office of Developmental Programs may assist in obtaining a review.

In situations where the individual manifests serious impairments of adaptive functioning, the burden is on the examiner when certifying sub-average intellectual functioning to avoid misdiagnosis and to rule out such factors as emotional disorder, social conditions, sensory impairment, or other variables which might account for the deficits in adaptive functioning.

An individual’s cultural background, ethnic origin, language, and means of communication should be considered when conducting all evaluations and assessments. The assessor will arrange for interpreters, including communication via sign language, or make accommodations to ensure receptive and expressive communication needs are considered to assist in the evaluation process, as necessary. All efforts to adapt the IQ test to the individual's particular visual, motor, or language impairments must be described and documented in the individual’s file.

  1. Initial ICF/ORC Level of Care Evaluation for People with Autism Spectrum Disorder

There are four fundamental criteria that must be met prior to an individual with autism spectrum disorder being determined eligible for an ICF/ORC level of care:

1.The individual must have a diagnosis of autism spectrum disorder,

2.The individual must have adaptive skill deficits in three or more areas based on a standardized adaptive functioning test, and

3.The autism spectrum disorder must have occurred prior to age 22,

4.The individual must be recommended for an ICF/ORC level of care based on a medical evaluation.

The AE shall request documentation of the diagnosis of autism spectrum disorder during the intake and registration process. The following criteria must be met to document a diagnosis of autism spectrum disorder and ICF/ORC level of care:

1.A licensed psychologist, certified school psychologist, psychiatrist, developmental pediatrician, or licensed physician who practices psychiatry certifies that the individual has autism spectrum disorder as documented in a standardized diagnostic tool.

2.A Qualified Developmental Disability Professional (QDDP) who meets criteria established in 42 CFR 483.430(a) and the approved Consolidated and P/FDS Waivers certifies that the individual has impairments in adaptive behavior based on the results of a standardized assessment of adaptive functioning[4] which shows that the individual has substantial functional limitation in three or more of the following areas of major life activity:

  • self-care,
  • receptive and expressive language,
  • learning,
  • mobility,
  • self-direction,
  • capacity for independent living.

3.Documentation substantiates that the individual has had these conditions of adaptive functioning manifested during the developmental period which is from birth up to the individual’s 22nd birthday.[5]

4.Documentation of the medical evaluation may be either an examination performed by a licensed physician, physician's assistant, or nurse practitioner that states the individual is recommended for ICF/ORC level of care or a Form MA 51 completed by a licensed physician, physician's assistant, or nurse practitioner.

Documentation of the results of the standardized diagnostic assessment and the standardized assessment of adaptive functioning shall consist of all of the following:

  • Documentation by the certifying practitioner that the results are considered valid and consistent with the individual’s functional limitations.
  • A statement by the certifying practitioner as to whether the results indicate that the individual has autism spectrum disorder.

If the individual does not have documentation of a standardized diagnostic assessment and/or a standardized assessment of adaptive functioning, the AE will assist the individual in obtaining the necessary assessment(s). If it is unclear with existing documentation whether an individual has substantial functional limitation in three or more areas of major life activity, the AE will assist the individual in obtaining a secondary review. If necessary, the Office of Developmental Programs’ Bureau of Autism Services may assist in obtaining a review.

An individual’s cultural background, ethnic origin, language, and means of communication should be considered when conducting all evaluations and assessments. The assessor will arrange for interpreters, including communication via sign language, or make accommodations to ensure receptive and expressive communication needs are considered to assist in the evaluation process, as necessary. All efforts to adapt the standardized assessment to the individual's particular visual, motor, or language impairments must be described and documented in the individual’s file.

  1. Initial ICF/ORC Level of Care Evaluation for Children prior to the age of 9 with Developmental Disability

There are four fundamental criteria that must be met prior to a child with developmental disability being determined eligible for an ICF/ORC level of care:

  1. Have a diagnosis of developmental disability. Eligibility criteria is defined as the following: developmental disability which is defined as a condition of substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in an intellectual disability or autism, the disability manifested prior to the age of 9 and the disability is likely to continue indefinitely;
  1. Individual is 8 years of age or younger; and
  1. Substantial adaptive skills deficits in three or more areas of major life activity based on a standardized adaptive functioning; and
  1. Be recommended for an ICF/ORC level of care based on a medical evaluation.

The AE shall request documentation of the diagnosis of developmental disability that indicates probability of diagnosis of ID or autism during the intake and registration process. The following criteria must be met to document a diagnosis of developmental disability and ICF/ORC level of care:

  1. A licensed psychologist, certified school psychologist, psychiatrist, developmental pediatrician or licensed physician who practices psychiatry certifies that the individual has developmental disability which is defined as a condition of substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in an intellectual disability or autism likely to continue indefinitely as documented in a standardized diagnostic tool.
  1. A Qualified Developmental Disability Professional (QDDP) who meets criteria established in 42 CFR 483.430(a) and the approved Consolidated and P/FDS Waivers certifies that the individual has impairments in adaptive behavior based on the results of a standardized assessment of adaptive functioning which shows that the individual has substantial functional limitation in three or more of the following areas of major life activity:
  2. self-care,
  3. receptive and expressive language,
  4. learning,
  5. mobility,
  6. self-direction,
  7. capacity for independent living.
  1. The child is 8 years of age or younger.
  1. Documentation of the medical evaluation may be either an examination performed by a licensed physician, physician's assistant, or nurse practitioner that states the individual is recommended for ICF/ORC level of care or a Form MA 51 completed by a licensed physician, physician's assistant, or nurse practitioner.

If the child does not have documentation of a standardized diagnostic assessment and/or a standardized assessment of adaptive functioning, the AE will assist the individual in obtaining the necessary assessment(s). If it is unclear with existing documentation whether an individual has substantial functional limitation in three or more areas of major life activity, the AE may assist the individual in obtaining a secondary review.

In situations where the child manifests serious impairments of adaptive functioning, the burden is on the examiner when certifying developmental disability with likelihood of ID or autism diagnosis to avoid misdiagnosis and to rule out such factors as emotional disorder, social conditions, sensory impairment, or other variables which might account for the deficits in adaptive functioning.

A child’s cultural background, ethnic origin, language, and means of communication should be considered when conducting all evaluations and assessments. The assessor will arrange for interpreters, including communication via sign language, or make accommodations to ensure receptive and expressive communication needs are considered to assist in the evaluation process, as necessary. All efforts to adapt the standardized diagnostic assessment to the child’s particular visual, motor, or language impairments must be described and documented in the individual’s file.

Individual Circumstances Where Testing may be Waived for Level of Care Determinations or Re-Determinations

Testing may not be appropriate for all individuals even though the Office of Developmental Programs believes that all people can be evaluated or assessed. Documentation of the efforts to test individuals along with the results of the test should be kept by the AE or County Program in the individual’s file until the case file is closed.

Testing may be waived in the following circumstances:

The requirement for a standardized general intelligence test may be waived for a person who is profoundly intellectually impaired to the extent that the use of standardized measures is precluded. In such a situation, the requirement for the standardized intelligence test shall be substituted by a written statement from a licensed psychologist, certified school psychologist, developmental pediatrician, psychiatrist or licensed physician who practices psychiatry that the person’s inability to be tested is itself a manifestation of significantly sub-average intellectual functioning.

The requirement for a standardized general intelligence test may be waived for a child under the age of 9 years who is profoundly intellectually impaired to the extent that the use of standardized measures is precluded. In such a situation, the requirement for the standardized intelligence test shall be substituted by a written statement from a licensed psychologist, certified school psychologist, developmental pediatrician, psychiatrist or licensed physician who practices psychiatry that the person’s inability to be tested is itself a manifestation of significantly sub-average intellectual functioning.

The requirement for a standardized general intelligence test and/or assessment of adaptive functioning may also be waived for an individual who received Medicaid Waiver services after living in an ICF/ID or ICF/ORC where it was determined that the individual met level of care. This requirement can be waived only upon the AE’s or County Program’s acceptance of a utilization review which affirms the individual’s need for an ICF/ID or ICF/ORC level of care. The utilization review must be completed in accordance with 42 CFR Part 456 for individuals in ICFs/ID and be dated within 365 days prior to the AE’s or County Program’s determination of need for an ICF/ID or ICF/ORC level of care.

Notification of Results of Review

The AE is responsible to complete the MA-250 (Attachment A) and notify the individual and family the results of the review for ICF/ID or ICF/ORC initial evaluations. Letter templates which include the specific level of care and status of Waiver availability are attached. (Attachment B, C and F).

Section 2: Annual ICF/ID or ICF/ORC Level of Care Re-evaluation Process

All individuals enrolled in the Consolidated or P/FDS Waiver require annual re-evaluation of need for an ICF/ID or ICF/ORC level of care to continue to qualify for services funded under the Waivers. The AE is responsible to recertify need for an ICF/ID or ICF/ORC level of care based on the evaluation and certification of a QDDP. The first re-evaluation of need for an ICF/ID or ICF/ORC level of care is to be made within 365 days of the individual's initial determination, and subsequent re-evaluations are made within 365 days of the individual’s previous re-evaluation.

The re-evaluation process must be completed by the QDDP, and the AE or County Program signatures must be obtained before the end of each 365 day timeframe. Form DP 251, “Annual Re-evaluation of Need for ICF/ID or ICF/ORC Level of Care” (Attachment D) will be used to document the re-evaluation and obtain the AE signature. A new 365 day timeframe starts the day after the AE date of signature on the completed DP 251 form.

Effective July 1, 2017, ODP will utilize the Supports Intensity Scale (SIS) assessment in the re-evaluation process. To conduct the re-evaluation, the QDDP should complete the Waiver Level of Care Re-Evaluation form (Attachment E). The Waiver re-evaluation process utilizes the SIS scores to determine if the waiver participant continues to meet ICF/ID or ICF/ORC Level of Care. The re-evaluation process will only use the standard scores indicated in the SIS Report. The QDDP must recertify that the individual continues to require an ICF/ID or ICF/ORC level of care. The assessment must include a review of the individual’s ISP to validate that the Waiver services authorized for the individual are beneficial and necessary as a direct result of the individual’s qualifying diagnosis.