§ 4226.23. Eligibility for Medicaid waiver services.
(a) The county MH/MR program shall ensure that infants and toddlers with disabilities enrolled in the Infant, Toddlers and Families Medicaid Waiver meet the level of care criteria for an intermediate care facility/mental retardation (ICF/MR) or intermediate care facility/other related conditions (ICF/ORC) as set forth in subsection (b).
(b) Eligibility criteria for ICF/MR or ICF/ORC level of care.
(1) Minimum eligibility for ICF/MR or ICF/ORC level of care is established by one of the following:
(i) A licensed psychologist, certified school psychologist or licensed physician shall certify that the infant or toddler has significantly subaverage intellectual functioning which is documented by one of the following:
(A) Performance that is more than two standard deviations below the mean as measured on a standardized general intelligence test.
(B) Performance that is slightly higher than two standard deviations below the mean as measured on a standardized general intelligence test during a period when the infant or toddler manifests serious impairments of adaptive behavior.
(ii) A qualified professional who meets the criteria in 42 CFR 483.430(a) (relating to condition of participation: facility staffing), shall certify that the infant or toddler has other related conditions, which may include cerebral palsy and epilepsy as well as other conditions except mental illness, such as autism, that result in impairments of general intellectual functioning or adaptive behavior and require early intervention services.
(2) In addition to the certification required in paragraph (1), a qualified professional who meets the criteria in 42 CFR 483.430(a) shall certify that the infant or toddler has impairments in adaptive behavior, which are likely to continue for at least 12 months, as documented by an assessment of adaptive functioning which shows one of the following:
(i) Significant limitations in meeting the standards of maturation, learning, personal independence or social responsibility of the infant’s or toddler’s age and cultural group, as evidenced by a minimum of a 50% delay in one or a 33% delay in two of the following developmental areas:
(A) Cognitive development.
(B) Physical development, including vision and hearing.
(C) Communication development.
(D) Social and emotional development.
(E) Adaptive development.
(ii) Substantial functional limitation in three or more of the following areas of major life activities:
(A) Self-care.
(B) Receptive and expressive language.
(C) Learning.
(D) Mobility.
(E) Self-direction.
(F) Capacity for independent living.
(G) Economic self-sufficiency.
(c) The county MH/MR program shall cooperate with the county assistance office in determining the initial and continuing financial eligibility of an infant or toddler with a disability and the infant or toddler’s family for waiver services.
Cross References This section cited in 55 Pa. Code § 4226.91 (relating to parental consent).
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