Section 117.140  Application and eligibility determination process

a)         The Department shall send and ask applicants chosen through the random selection process to complete an application package (described in subsection (b) of this Section) within 30 days after being notified that they have been chosen.

b)         The application package shall include:  

1)         A letter explaining the Department's eligibility verification process;

2)         Instructions for submitting the necessary clinical information to verify the severity of the disability and other eligibility criteria;

3)         A listing of Department-designated agencies in the applicant's region which may assist with verification of disability;

4)         Written instructions to the primary examiners on what they must do to verify eligibility;

5)         Eligibility criteria for individuals with severe mental illness or emotional disturbance, severe autism, severe mental retardation and severe and multiple impairments; and

6)         Eligibility determination forms that must be signed by the primary examiner (see Section 117.Appendix B).

c)         Documentation of a severe or profound mental retardation shall be based on a comprehensive documented evaluation by a licensed clinical psychologist or a certified school psychologist for children or for adults up to the age of 21 sho are in a special education program.  The evaluation shall verify that the individual's severe or profound mental retardation originated before the age of 18 and has resulted in significantly subaverage general intellectual functioning in concurrence with impairment in adaptive behavior and meets the Classification in Mental Retardation (American Association on Mental Retardation, 1983 edition) or the DSM-III-R criteria of severe or profound mental retardation, i.e., an intelligence quotient (I.Q.) of 40 or below, and a severe or profound level of adaptive behavior in keeping with illustrations in the Classification in Mental Retardation.

d)         Documentation of a severe mental illness shall be based on a comprehensive documented evaluation by a licensed clinical psychologist or psychiatrist.  The evaluation shall verify that the individual's primary diagnosis meets one of the DSM-III-R major mental disorders listed below (such diagnosis may coexist with other DSM-III-R diagnoses in Axis I or other areas):  schizophrenic disorder; delusional disorder; schizoaffective disorder; bipolaraffective disorder; atypical psychosis; or major depression, recurrent.  The evaluation shall also verify that the individual's severe mental illness has substantially affected his or her functioning in at least two of the following areas:  self maintenance, social functioning, activities of community living, work skills.  There shall be detailed documentation of how the individual's functioning in these areas has been specifically affected and documentation that the substantial functional disabilities are expected to be present for at least one year, which results in substantial limitations in major life activities.

e)         Documentation of severe autism shall be based on a comprehensive, documented evaluation by a licensed clinical psychologist or psychiatrist. The evaluation shall verify that a child or adult with severe autism has a lifelong developmental disability which is typically manifested before 30 months of age and is characterized by disturbances in the rate and sequences of cognitive, affective, psychomotor, language and speech development.  The diagnosis of autistic disorder shall be in keeping with DSM-III-R 299.00 criteria of autistic disorder.

f)         Documentation of severe and multiple impairments shall be based on a comprehensive, documented evaluation by a licensed clinical psychologist or a physician; and, depending on the individual's disability, one or more specialists.  The evaluation shall verify that the individual has a substantial disability that can be expected to continue indefinitely.  The individual meets the criteria for severe and multiple impairments based on a finding that criteria in subsections (f)(1) through (3) of this Section are met.  Each item has its own sub-criteria which also shall be met, e.g., under subsection (f)(1)(A) or (B) of this Section, shall apply.

1)         The evaluation determines the presence of a developmental disability based on:

A)        Mental retardation, which is defined as general intellectual functioning that is two or more standard deviations below the mean; or

B)        Cerebral palsy, epilepsy, autism or any other condition which results in impairment similar to that caused by mental retardation and which requires services similar to those required by persons with mental retardation.

2)         The evaluation determines multiple handicaps in physical, sensory, behavioral and/or cognitive functioning which constitute a severe or profound impairment attributable to one or more of the following:

A)        Physical functioning, which severely impairs or restricts the individual's motor performance that may be due to neurological, psychological or physical involvement resulting in a variety of disabling conditions, such as hemiplegia, quadriplegia, ataxia, in severe organ systems involvement such as congential defects, and other physical abnormalities resulting in the individual being non-mobile and non-ambulatory or confined to bed and receiving assistance in transferring, or requiring regular medical or nursing supervision such as gastrostomy care and feeding.

B)        Sensory, which involves severe restriction due to hearing and/or visual impairment limiting the individual's movement and creating dependence in completing most daily activities.

i)          Hearing impairment is defined, based on an evaluation by a board eligible or certified otolaryngologist or an audiologist with a Certificate of Clinical Competency, as loss of 70 dB aided or speech discrimination of less than 50% aided.

ii)         Visual impairment is defined, based on an evaluation by a board eligible or certified ophthamologist or a licensed optometrist, as 20/200 in the better eye or a visual field of 20 degrees or less.

C)        Behavioral, which involves severe or profound deficits in adaptive hehavior or severe maladaptive behavior.

i)          Adaptive behavior, which is at a severe or profound level of functioning for the age group in self-care skills such as feeding, dressing, grooming or bathing, in social skills such as responses or interactions with others or in communication skills such as use of words or gestures expressively or receptively.

ii)         Maladaptive behavior, which presents a danger to self or others, is destructive to property by deliberately breaking, destroying or defacing objects, is disruptive by fighting or prolonged arguing or crying, or has other socially offensive behaviors in sufficient frequency and/or severity to seriously limit social integration.

D)        Cognitive, which involves severe or profound intellectual functioning at a measured I.Q. of 40 or below.

3)         The evaluation determines that development is substantially less than expected for the individual's age in cognitive, affective or psychomotor behavior.

A)        Cognitive, which involves intellectual functioning at a measured I.Q. of 70 or below.

B)        Affective behavior, which involves over and under responding to stimuli in the environment and may be observed in mood, attention or awareness, or in behaviors such as euphoria, anger or sadness that seriously limit integration into society.

C)        Psychomotor, which includes a severe developmental delay in fine or gross motor skills so that development in self-care, social interaction, communication or physical activity shall be greatly delayed or restricted.

g)         Individuals or their guardians may use existing evaluations if they meet the criteria above and were completed within the following time frames:

1)         For assessment of severe mental illness described in subsection (d) of this Section, within one year prior to the date submitted to the Department.

2)         For assessment of the maladaptive behavior component of severe and multiple impairment described in subsection (f)(2)(C)(ii) of this Section, within one year prior to the date submitted to the Department.

3)         For all other assessments required by subsections (c)(e) and (f) of this Section, within three years prior to the date submitted to the Department.

h)         If existing evaluations are not available, outdated or do not meet the above criteria, individuals or their guardians shall choose the primary examiner of their choice or use Department-designated agencies or organizations to conduct the evaluations.  The completed evaluation shall be submitted with forms DMHDD-1237.1, 1237.2, 1237.3, 1237.4, 1237.5 (see Section 117.Appendix B, Illustrations A, B, C, D, E).

i)          The Department shall reimburse primary examiners and the other necessary examiners for the cost of the evaluation unless the individuals are eligible for partial or full payment for the evaluation by a third party payor.  In such cases, the third party payor shall reimburse for the full or partial cost, depending on the individuals' coverage, and the Department shall reimburse the balance.  The Department's reimbursement shall be tied to the usual and customary fee for such evaluations, based on the individuals' needs.

j)          The primary examiner shall submit the completed application and verification of disability to the Department.

k)         The Department shall review the completed application and verification of disability.  The Department shall notify the applicant in writing within 30 days that the application has been received and is or is not complete, and shall specify in writing what additional information is necessary.

l)          Should an application remain incomplete for more than 30 days after the request for additional information, the Department shall notify the applicant in writing of the incomplete status and what information is still lacking. Such notification of status shall be sent one additional time at a 30-day interval.  If, within 30 days after the final notification, the applicant has not provided the additional information, the application shall be considered inactive.