Idaho Admin. Code r. 16.03.10.522

Current through September 2, 2024

Section 16.03.10.522 - CHILDREN'S DD HCBS STATE PLAN OPTION: ELIGIBILITY DETERMINATION

Final determination of a participant's eligibility will be made by the Department.

01.Initial Eligibility Assessment Developmental Disability Determination. The Department, or its contractor, will determine if a child meets established criteria for a developmental disability by completing the following:

a. Documentation of a participant's developmental disability diagnosis, demonstrated by:

i. A medical assessment that contains medical information that accurately reflects the current status of the participant or establishes categorical eligibility in accordance with Section 66-402(5)(a), Idaho Code; or

ii. The results of psychometric testing, if eligibility for developmental disabilities services is based on intellectual disability and there is no prior testing, or prior testing is inconclusive or invalid. Initial eligibility determinations also require documentation of diagnosis for a participant whose eligibility is based on developmental disabilities other than intellectual disability.

b. An assessment of functional skills that reflects the participant's current functioning. The Department, or its contractor, will administer a functional assessment for use in initial eligibility determination of developmental disability eligibility. Annually, a new functional assessment may be required if the assessor determines that additional documentation is necessary to determine the participant's level of care criteria and must be completed sixty (60) calendar days before the expiration of the current plan of service.

c. Medical, social, and developmental assessment (MSDA) summary.

02.Determination for Children's DD HCBS State Plan Option. The Department, or its contractor, will determine if a child meets the established criteria necessary to receive children's DD HCBS state plan option services by verifying:

a. The participant is birth through seventeen (17) years of age; and

b. The participant has a developmental disability as defined under Sections 500, 501, and 503 these rules and Section 66-402, Idaho Code, and has a demonstrated need for Children's DD HCBS state plan option services; and

c. The participant qualifies for Medicaid under an eligibility group who meets the needs-based criteria of the 1915(i) benefit for children with developmental disabilities and falls within the income requirements as specified in Attachment 2.2-A of the Idaho State Plan under Title XIX.

03.Individualized Budget Methodology. The following four (4) categories are used when determining individualized budgets for children with developmental disabilities.

a. Children's DD - Level I. Children meeting developmental disabilities criteria.

b. Children's DD - Level II.

i. Children who qualify based on functional limitations when their composite full-scale standard score of less than fifty (50); or

ii. Children who have an overall standard score up to fifty-three (53) when combined with a maladaptive behavior score of greater than one (1) to less than two (2) standard deviations from the mean.

c. Children's DD - Level III.

i. Children who qualify based on functional limitations when their composite full-scale standard score is less than fifty (50); and

ii. Have an autism spectrum disorder diagnosis.

d. Children's DD - Level IV. Children who qualify based on maladaptive behaviors when their maladaptive behavior score is two (2) standard deviations or greater from the mean.

04.Participant Notification of Budget Amount. The Department, or its contractor, will notify each participant of his set budget amount as part of the eligibility determination process. The notification will include how the participant may appeal the set budget amount.

05.Annual Re-Evaluation. Individualized budgets will be re-evaluated annually. At the request of the participant, the Department, or its contractor, will also re-evaluate the set budget amount when there are documented changes that may support placement in a different budget category as outlined in Subsection 522.03 of this rule.

Idaho Admin. Code r. 16.03.10.522

Effective March 17, 2022