Or. Admin. Code § 411-320-0080
Current through Register Vol. 63, No. 12, December 1, 2024
Section 411-320-0080 - Application and Eligibility Determination(1) APPLICATION. (a) To apply for developmental disabilities services:(A) An applicant, or the legal representative of the applicant, must submit a completed application to the CDDP in the county of origin.(B) The CDDP must receive all documentation required to make an eligibility determination. Documentation includes, but is not limited to: (i) School psychological or comprehensive evaluations since entry into school;(ii) Medical assessments related to a disability, mental health condition, or physical impairment;(iii) Psychological evaluations or comprehensive evaluations through private health insurance or other programs;(iv) Neurological evaluations completed through any entity;(v) Records from all residential or psychiatric facilities;(vi) Records completed through the application process for other governmental benefits; and(vii) Administrative medical examinations and reports, as defined in OAR 410-120-0000, determined necessary and authorized by an eligibility specialist.(C) The applicant must meet the Oregon residency requirements in OAR 461-120-0010 or if the applicant is less than 18 years of age, the applicant and the legal representative of the applicant must meet the Oregon residency requirements in OAR 461-120-0010.(b) The CDDP may stop the intake process if a Request for Eligibility Determination (form 0552) is voluntarily withdrawn or the documents listed in subsection (a)(B) of this section are not submitted within 90 calendar days from the date the CDDP received the signed and dated request. If the CDDP stops the intake process, written notice of the information needed to determine eligibility or a letter confirming voluntary withdrawal must be sent to the person identified on the request form as the person seeking services and the legal representative of the person seeking services.(c) The CDDP must consider an application complete if the criteria in subsection (a) of this section is met.(d) Within 10 business days from the receipt of a completed application, the CDDP must provide an applicant the following:(A) The Department required Notification of Rights (form 0948).(B) The Department's "Choosing Developmental Disabilities Services for Children and Adults" (form 0338).(C) For an adult applicant, the identities and contact information for each case management entity operating in the county of origin using materials provided by each case management entity when the materials are made available to the CDDP.(e) A new application may not be required if the following criteria are met:(A) The file for an individual has been closed for less than 12 months following a closure, denial (from the date the Request for Eligibility Determination (form 0552) was signed), or termination; and(B) The individual meets all of the criteria in subsection (a) of this section.(f) The CDDP must identify whether an applicant receives any income. (A) The CDDP must refer all applicants not currently receiving one of the following to the local Medicaid office for application and benefit determination:(i) A Medicaid Title XIX benefit package through OSIPM or HSD medical programs; or(ii) A benefit package through the Healthier Oregon medical program.(B) The CDDP must refer an applicant less than 18 years of age to Social Security if the CDDP identifies the applicant may qualify for Social Security benefits.(g) REINSTATEMENT OF ELIGIBILITY FOR CHILDREN OF SERVICE MEMBERS.(A) WAIVER OF APPLICATION. A previously eligible child of a service member, who temporarily left Oregon due to a parent's or guardian's military service obligation outside of Oregon, does not need to submit a new application for developmental disabilities services upon return. Upon return to Oregon and a request to the CDDP in the county of origin, the CDDP in the county of origin shall assign a services coordinator to the child within 10 business days from the request for services.(B) COORDINATION OF SERVICES. The services coordinator must assist the child in establishing eligibility for OSIPM or HSD medical programs and meet face-to-face with the child and their parent or guardian, within 45 calendar days from the request for services, to provide choice advising and to review the child's rights to a fair hearing and the service planning steps in OAR 411-415-0070.(C) REDETERMINATION. The CDDP must follow sections (6) and (7) of this rule regarding a redetermination of eligibility. As with all redeterminations, prior to a termination of developmental disabilities services, the CDDP must send a Notice of Redetermination (form 5101), afford the child's parent or guardian the opportunity to provide documentation that supports eligibility, and schedule a diagnostic evaluation for the child, if appropriate. Upon the child's reentry to services, the CDDP in the county of origin shall initiate a redetermination if: (i) The criteria used to determine eligibility for developmental disabilities services changed during the child's absence;(ii) There are new records related to the eligibility criteria for developmental disabilities services, including medical, psychological, or school records related to an intellectual or developmental disability; or(iii) The documents used to establish the child's original eligibility are more than three years old and medical, educational, or psychological records created during the child's absence do not support the child's eligibility for developmental disabilities services.(2) ELIGIBILITY SPECIALIST. Each CDDP must identify at least one qualified eligibility specialist to act as a designee of the Department for purposes of making an eligibility determination. The eligibility specialist must meet performance qualifications and training expectations for determining eligibility for developmental disabilities services as described in OAR 411-320-0030.(3) INTELLECTUAL DISABILITY. A history of an intellectual disability and significant impairment in adaptive behavior must be evident prior to the 18th birthday of an individual for the individual to be eligible for developmental disabilities services. (a) Diagnosing an intellectual disability is done by measuring intellectual functioning and adaptive behavior as assessed by standardized tests administered by a licensed clinical or school psychologist with specific training and experience in test interpretation of intellectual functioning and adaptive behavior scales for individuals with intellectual disabilities. FSIQ requirements are as follows. A Specific Index IQ result must be used in place of an FSIQ score to determine eligibility if a licensed clinical psychologist determines the Specific Index IQ is a more valid measure of overall intelligence when compared to the FSIQ. (A) For an individual who has consistent and valid FSIQ results of 65 or less, significant impairment in adaptive behavior is implied and no assessment of adaptive behavior may be needed if current documentation of impairment supports eligibility. If an individual has an assessment of adaptive behavior and results do not support eligibility, then the assessment of adaptive behavior must be considered.(B) For an individual who has a valid FSIQ or equivalent composite score results of 66-70, verification of an intellectual disability requires an assessment of adaptive behavior. The individual must have significant impairment in adaptive behavior.(C) For an individual who has a valid FSIQ or equivalent composite score results of 71-75, verification of an intellectual disability requires an assessment of adaptive behavior and diagnosis of intellectual disability from a licensed clinical psychologist. (i) The individual must have significant impairment in adaptive behavior.(ii) The individual must have a diagnosis of intellectual disability from a qualified professional.(iii) The individual must meet the full criteria for the diagnosis of the intellectual disability. Individuals with a "borderline", "provisional", "partial", "rule-out", or "un-specified" diagnosis do not meet the full criteria.(D) If an individual is not able to participate in an intelligence test due to intellectual disability, a statement of intellectual disability must be documented by a qualified professional and an assessment of adaptive behavior must be completed and demonstrate a composite score of at least two standard deviations below the mean.(b) Significant impairment in adaptive behavior must be directly related to an intellectual disability and cannot be primarily attributed to other conditions including, but not limited to, a mental or emotional disorder, sensory impairment, motor impairment, substance abuse, personality disorder, learning disability, or ADHD.(c) The condition and significant impairment must continue, or be expected to continue, indefinitely.(4) OTHER DEVELOPMENTAL DISABILITY. A history of an other developmental disability and significant impairment in adaptive behavior must be evident prior to the 22nd birthday of an individual for the individual to be eligible for developmental disabilities services. (a) Diagnosing an other developmental disability requires a medical or clinical diagnosis of a developmental disability by a qualified professional and significant impairment in adaptive behavior as assessed by standardized tests administered by a licensed clinical psychologist, school psychologist, doctor of medicine, or doctor of osteopathic medicine with specific training and experience in test interpretation of adaptive behavior scales for individuals with intellectual or developmental disabilities. The individual must meet the full criteria for the diagnosis of the developmental disability. Individuals with a "provisional", "partial", "rule-out", or "un-specified" diagnosis do not meet the full criteria. (A) Other developmental disabilities include, but are not limited to, autism, cerebral palsy, epilepsy, or other neurological disabling conditions that originate in and directly affect the brain.(B) The individual must have significant impairment in adaptive behavior which requires that the individual have one composite score two standard deviations below the mean, two domain scores two standard deviations below the mean, or two skilled areas on the ABAS or ABES two standard deviations below the mean on an approved adaptive assessment.(C) The individual must require training and support similar to that required by an individual with an intellectual disability, which means the individual has a composite or domain score that is at least two standard deviations below the mean, as measured on a standardized assessment of adaptive behavior administered by a licensed clinical psychologist, school psychologist, doctor of medicine, or doctor of osteopathic medicine with specific training and experience in test interpretation of adaptive behavior scales for individuals with intellectual or developmental disabilities.(b) To meet the requirements of significant impairment in adaptive behavior and qualify as a person who requires training and support similar to that required by an individual with an intellectual disability, an individual who has two skilled areas on the ABAS or ABES two standard deviations below the mean must also have at least one composite or domain score two standard deviations below the mean.(c) Significant impairment in adaptive behavior must be directly related to the diagnosed developmental disability and cannot be primarily attributed to other conditions including, but not limited to, a mental or emotional disorder, sensory impairment, motor impairment, substance abuse, personality disorder, learning disability, or ADHD.(d) The condition and significant impairment must continue, or be expected to continue, indefinitely.(5) PRESUMPTIVE ELIGIBILITY. (a) An individual who meets all eligibility criteria in this section must be found presumptively eligible for up to 12 months or until eligibility is determined under section (3) or (4) of this rule.(b) Presumptive eligibility is met when:(A) An individual has: (i) An FSIQ of 65 or less; or(ii) Documentation of inability to complete intelligence tests due to cognitive limitations.(B) An individual has a qualifying developmental disability and has specific and significant limitations in mobility, communication, or personal care, as noted in medical records implying significant impairment in adaptive behavior.(c) Co-occurring conditions may not primarily contribute to significant impairment of adaptive behavior as described in sections (3) and (4) of this rule.(d) If documentation of significant impairment in adaptive behavior by a qualified professional is required by rule and cannot be obtained timely due to circumstances outside of an individual's or CDDP's control:(A) An eligibility specialist must obtain a current physician's statement by a qualified professional identifying areas of adaptive behavior that are most likely significantly impaired by a qualifying condition; or(B) The CDDP must complete an informal adaptive behavior assessment implying significant impairment in adaptive behavior as defined in OAR 411-320-0020.(e) An individual presumed eligible during the federal public health emergency for COVID-19 must be redetermined eligible and meet section (3) or (4) of this rule no later than 12 months from the end of the federal public health emergency.(f) An individual determined presumptively eligible must continue to work with the CDDP during the eligibility determination process described in section (11) of this rule. If an individual is not working with the CDDP to complete the determination process, the CDDP must issue a Notification of Planned Action (form 0947).(6) ELIGIBILITY FOR EARLY CHILDHOOD. (a) Eligibility determinations for early childhood (children less than 7 years of age) must be based on documentation that is no more than one year from the date of the Request for Eligibility Determination (form 0552).(A) The documentation must include:(i) A valid standardized and normed early childhood assessment, completed by a professional with at least a master's degree and training to administer early childhood assessments, which demonstrates the functioning of the child is at least two standard deviations below the mean in two or more areas of the adaptive behavior described in paragraph (B) of this subsection; or(ii) When a standardized and normed early childhood assessment is not available or not completed within one year from the date of the Request for Eligibility Determination (form 0552), a medical statement by a licensed medical practitioner that confirms the presence of an other developmental disability that is a neurological condition or syndrome that originates in and directly affects the brain and causes or is likely to cause impairment in at least two or more areas of the adaptive behavior described in paragraph (B) of this subsection is required.(B) Areas of adaptive behavior include: (i) Adaptive, self-care, or self-direction;(ii) Receptive and expressive language or communication;(iii) Learning or cognition;(iv) Gross and fine motor; or(C) The impairment, condition, or syndrome cannot be primarily attributed to other conditions including, but not limited to, a mental or emotional disorder, sensory impairment, motor impairment, substance abuse, personality disorder, learning disability, or ADHD.(D) The condition and impairment must continue, or be expected to continue, indefinitely.(b) REDETERMINATION OF ELIGIBILITY. (A) Eligibility for early childhood is always provisional.(i) Redetermination for school-aged eligibility for a child who was originally determined using a standardized and normed early childhood assessment as described in subsection (b)(A)(i) of this section must be completed no later than the child's 9th year birthdate.(ii) Redetermination for school-aged eligibility for a child who was originally determined using a medical statement by a licensed medical practitioner as described in subsection (b)(A)(ii) of this section must be completed no later than the child's 7th year birthdate.(B) Any time there is evidence that contradicts an eligibility determination, the Department or the designee of the Department may redetermine eligibility or obtain additional information, including securing an additional evaluation for clarification purposes.(C) The CDDP must notify a child and the legal representative of the child any time that a redetermination of eligibility is needed. The Notice of Redetermination (form 5101), including the reason for the review of eligibility, must be sent prior to the eligibility redetermination date.(7) ELIGIBILITY FOR SCHOOL-AGED CHILDREN. Eligibility for school-aged children is always provisional. (a) Eligibility determinations for school-aged children must be completed on children who are at least 5 years of age and who have had school-aged testing completed.(b) Eligibility determinations for school-aged children may be completed:(A) Up to age 18 for school-aged children who are provisionally eligible based on a condition of an intellectual disability; and(B) Up to age 22 for school-aged children who are provisionally eligible based on a diagnosed condition of an other developmental disability.(c) Eligibility determinations for school-aged children must include:(A) Documentation of an intellectual disability and significant impairment in adaptive behavior as described in section (3) of this rule; or(B) A diagnosis and documentation of an other developmental disability and significant impairment in adaptive behavior as described in section (4) of this rule.(d) Eligibility determinations for school-aged children must be based on documentation that is no more than three years old from the date of the Request for Eligibility Determination (form 0552).(e) REDETERMINATION OF ELIGIBILITY.(A) Any time there is evidence that contradicts an eligibility determination, the Department or the designee of the Department may redetermine eligibility or obtain additional information, including securing an additional evaluation for clarification purposes.(B) The CDDP must notify a school-aged child and the legal representative of the child any time that a redetermination of eligibility is needed. The Notice of Redetermination (form 5101), including the reason for the review of eligibility, must be sent prior to the eligibility redetermination date.(f) REDETERMINATION OF SCHOOL-AGED CHILDREN FOR ADULT ELIGIBILITY.(A) Redetermination of school-aged children for adult eligibility must be completed: (i) Between the ages of 16 and 18 if school-aged eligibility was determined based on an intellectual disability as described in section (3) of this rule; or(ii) Between the ages of 17 and 22 if school-aged eligibility was determined based on an other developmental disability as described in section (4) of this rule.(B) The documentation of an intellectual disability or an other developmental disability must include information no more than three years old from the date of the Notice of Redetermination (form 5101), for individuals less than 22 years of age.(C) If school-aged eligibility was determined based on an intellectual disability as described in section (3) of this rule the following criteria may be applied:(i) An adult intelligence test may be used to determine adult eligibility. An intelligence test completed within the last three years from the date of the Notice of Redetermination (form 5101) is not needed if the school-aged child has:(I) More than one, and the most recent intelligence test FSIQ score is 65 or less as described in section (3)(a)(A) of this rule;(II) Significant impairment in adaptive behavior as identified in section (3) of this rule; and(III) Current documentation that supports eligibility.(ii) An informal adaptive behavior assessment may be completed if all of the following apply: (I) An assessment of adaptive behavior is required to redetermine eligibility;(II) An assessment of adaptive behavior has already been completed by a licensed school or clinical psychologist; and(III) The school-aged child has obvious significant impairment in adaptive behavior.(D) If school-aged eligibility was determined based on an other developmental disability as described in section (4) of this rule, the following criteria must be met: (i) A current medical or clinical diagnosis of an other developmental disability is required unless all of the following are met:(I) Documentation of an other developmental disability by a qualified professional as described in section (4) of this rule;(II) Significant impairment in adaptive behavior that continues to be directly related to the other developmental disability;(III) Current documentation that continues to support eligibility; and(IV) No other medical, mental, emotional, motor, or learning disorders.(ii) If an individual has additional medical, mental, or emotional disorders, a new assessment may be required.(iii) An informal adaptive behavior assessment may be completed if all of the following apply: (I) An assessment of adaptive behavior is required to redetermine eligibility;(II) An assessment of adaptive behavior has already been completed by a licensed school or clinical psychologist; and(III) The school-aged child has obvious significant impairment in adaptive behavior.(8) ELIGIBILITY FOR ADULTS.(a) Eligibility for adults must include:(A) Documentation of an intellectual disability and significant impairment in adaptive behavior as described in section (3) of this rule; or(B) Documentation of an other developmental disability and significant impairment in adaptive behavior as described in section (4) of this rule.(b) Documentation for an adult eligibility determination must include:(A) Information no more than three years old from the date of the Request for Eligibility Determination (form 0552) for individuals less than 22 years of age; or(B) Information obtained after the 17th birthday of an individual for individuals 22 years of age and older.(c) INTELLIGENCE TEST.(A) An adult intelligence test completed on or after the age of 16 may be used to determine adult eligibility.(B) An intelligence test may not be needed if an individual has:(i) More than one intelligence test verifying intellectual disability and the most recent FSIQ score is 65 or less as described in section (3)(a)(A) of this rule; and(ii) Significant impairment in adaptive behavior as identified in section (3) of this rule.(C) An intelligence test may not be needed if an individual has a diagnosis and documentation of an other developmental disability as described in section (4) of this rule.(d) REDETERMINATION OF ELIGIBILITY.(A) Any time there is evidence that contradicts an eligibility determination, the Department or the designee of the Department may redetermine eligibility or obtain additional information, including securing an additional evaluation for clarification purposes.(B) The CDDP must notify an individual, and if applicable the legal representative of the individual, any time that a redetermination of eligibility is needed. The Notice of Redetermination (form 5101), including the reason for the review of eligibility, must be sent prior to the eligibility redetermination date.(C) In the event the eligibility of an adult requires a redetermination, the redetermination must be completed as described in subsections (a), (b), and (c) of this section.(9) ABSENCE OF DATA IN DEVELOPMENTAL YEARS.(a) In the absence of sufficient data during the developmental years, current data may be used if:(A) There is no evidence of head trauma;(B) There is no evidence or history of significant mental or emotional disorder; or(C) There is no evidence or history of substance abuse.(b) If there is evidence or a history of head trauma, significant mental or emotional disorder, or substance abuse, then a clinical impression by a qualified professional regarding how the functioning of the individual may be impacted by the identified condition must be obtained in order to determine if the significant impairment in adaptive behavior is directly related to an intellectual or developmental disability and not primarily related to a head trauma, significant mental or emotional disorder, or substance abuse.(10) SECURING EVALUATIONS. In the event that an eligibility specialist has exhausted all local resources to secure the necessary evaluations for an eligibility determination, the Department or the designee of the Department shall assist in obtaining additional testing if required to complete the eligibility determination.(11) PROCESSING ELIGIBILITY DETERMINATIONS. The CDDP, in the county of origin, is responsible for making the eligibility determination.(a) The CDDP must work in collaboration with the individual or the legal representative of the individual to gather historical records related to the intellectual or an other developmental disability of an individual during intake in order to complete an application for services.(b) The CDDP must review documents and complete necessary actions relating to timely decisions within 30 calendar days of receipt of application and related documents. The CDDP must review at a minimum every 30 days thereafter to identify if a determination may be made under sections (3) through (8) of this rule.(c) During intake, the CDDP must gather enough documentation in order to accept a completed application for developmental disabilities services within 90 calendar days of the date of intake, except in the following circumstances: (A) The CDDP is unable to obtain a complete application because the individual or the legal representative of the individual does not collaborate with the eligibility specialist or fails to execute an action necessary to obtain a completed application;(B) There is an emergency beyond the control of the CDDP; or(C) More time is needed to obtain additional records by the CDDP, the individual, or the legal representative of the individual.(d) Upon receipt of the completed application, the CDDP must make an eligibility determination unless the following applies and is documented in the progress notes for an individual: (A) The individual or the legal representative of the individual voluntarily withdraws the application for the individual;(B) The individual dies; or(C) The individual cannot be located.(e) The CDDP may not use the time frames established in subsection (c) of this section as: (A) A waiting period before determining eligibility; or(B) A reason for denying eligibility.(12) PROGRESS NOTES. An eligibility specialist must document progress notes of the intake process including, but not limited to, the following:(b) Referral source to the CDDP.(d) Rationale for presumptive eligibility criteria or why presumptive eligibility is not met.(e) Rationale for ordering administrative exams.(f) Rationale for eligibility determination or redetermination, including specific age category and description criteria evidenced on record that meets sections (3) or (4) of this rule.(g) Information on when and how the decision notice was sent to an individual and their legal representative and the effective date.(h) Information regarding an administrative hearing including, but not limited to, the date a request for hearing was made and date the hearing request was submitted to the Department.(i) Receipt of eligibility and related actions during a county to county transfer.(13) NOTICE OF ELIGIBILITY DETERMINATION. Within 10 business days from the receipt of a completed application, the CDDP must send or hand deliver a written notification (notice) of the eligibility determination to the individual or their legal representative. The notice must be on the following forms prescribed by the Department: (a) Notice of Eligibility Determination (form 5103) or Notice of Presumptive Eligibility.(b) Notification of Planned Action (form 0947).(14) REQUESTING A HEARING. An individual or the legal representative of an individual may request a hearing as described in OAR 411-318-0025 if the individual or the legal representative of the individual disagrees with the eligibility determination or redetermination made by the CDDP.(15) TRANSFERABILITY OF ELIGIBILITY DETERMINATION. An eligibility determination made by one CDDP must be honored by another CDDP when an individual moves from one county to another within Oregon. (a) The receiving CDDP must notify the individual, and if applicable the legal representative of the individual, on forms prescribed by the Department that a transfer of services to a new CDDP has taken place within 10 business days of the enrollment date identified on the Developmental Disabilities Eligibility and Enrollment Form (form 0337).(b) The receiving CDDP must continue services for the individual as soon as it is determined that the individual is residing in the county of the receiving CDDP.(c) The receiving CDDP must obtain and retain copies of the following documents:(A) Statement of an eligibility determination.(B) Notification of eligibility determination.(C) Evaluations and assessments supporting eligibility.(d) In the event that the items in subsection (c) of this section cannot be located, written documentation from the sending CDDP verifying eligibility and enrollment in developmental disabilities services may be used. Written verification may include documentation from the Department's electronic payment and reporting system.(e) If the receiving CDDP receives information that suggests the individual is not eligible for developmental disabilities services, the receiving CDDP may complete a redetermination. The CDDP that determined the individual was eligible for developmental disabilities services may be responsible for the services authorized on the basis of their eligibility determination.(f) If an individual submits an application for developmental disabilities services and discloses that they previously received developmental disabilities services in another CDDP and the termination of case management services as described in OAR 411-415-0030 occurred within the past 12 months, the eligibility determination from the other CDDP shall transfer as outlined in this section.Or. Admin. Code § 411-320-0080
SPD 24-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 28-2004, f. & cert. ef. 8-3-04; SPD 16-2005(Temp), f. & cert. ef. 11-23-05 thru 5-22-06; SPD 5-2006, f. 1-25-06, cert. ef. 2-1-06; SPD 9-2009, f. & cert. ef. 7-13-09; SPD 6-2010(Temp), f. 6-29-10, cert. ef. 7-4-10 thru 12-31-10; SPD 28-2010, f. 12-29-10, cert. ef. 1-1-11; SPD 31-2011, f. 12-30-11, cert. ef. 1-1-12; SPD 57-2013, f. 12-27-13, cert. ef. 12-28-13; APD 23-2014(Temp), f. & cert. ef. 7-1-14 thru 12-28-14; APD 41-2014, f. 12-26-14, cert. ef. 12/28/2014; APD 36-2015(Temp), f. 12-31-15, cert. ef. 1-1-16 thru 6-28-16; APD 16-2016, f. 6-28-16, cert. ef. 6/29/2016; APD 38-2018, temporary amend filed 11/07/2018, effective 11/08/2018 through 04/30/2019; APD 43-2018, temporary amend filed 12/18/2018, effective 12/18/2018 through 04/30/2019; APD 18-2019, amend filed 04/30/2019, effective 5/1/2019; APD 17-2020, temporary amend filed 05/13/2020, effective 05/13/2020 through 11/08/2020; APD 42-2020, amend filed 10/09/2020, effective 10/15/2020; APD 34-2022, temporary amend filed 07/01/2022, effective 7/1/2022 through 12/27/2022; APD 53-2022, amend filed 12/14/2022, effective 12/15/2022; APD 4-2023, amend filed 04/28/2023, effective 5/1/2023Statutory/Other Authority: ORS 409.050, 427.104, 427.105, 427.115, 427.154 & 430.662
Statutes/Other Implemented: ORS 409.010, 427.005-427.154, 430.215, 430.610, 430.620, 430.662 & 430.664