OAR 411-320-0080: Application and Eligibility Determination for Developmental Disabilities Services

(1) APPLICATION (form 0552). (a) To apply for developmental disabilities services: (A) An applicant, or their legal representative, must submit an application to the Community Developmental Disabilities Program (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 relating to substance use; (vii) Records completed through the application process for other governmental benefits; and (viii) 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. If the applicant is less than 18 years of age, the applicant and their legal representative must meet the Oregon residency requirements in OAR 461-120-0010. (b) The CDDP may stop the eligibility process if: (A) An application is voluntarily withdrawn; or (B) The documents listed in subsection (a)(B) of this section are not submitted within 90 calendar days from the date of the intake. (c) When the CDDP stops the eligibility determination process, the CDDP must send the applicant or their legal representative either: (A) Written notice, on a Department-approved form, identifying the information needed to determine eligibility; or (B) A letter confirming voluntary withdrawal. (d) The CDDP must consider an application complete if the criteria in subsection (a) of this section is met. (e) Within 10 business days from the receipt of a completed application, the CDDP must provide an applicant, or the applicant’s legal representative, all of 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. (f) 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 application was signed), or termination; and (B) The individual meets all of the criteria in subsection (a) of this section, and a redetermination according to this rule was not required before the date of the new request. (g) 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 Oregon Supplemental Income Program-Medical (OSIPM) or Health Systems Division medical programs. (ii) A benefit package through Healthier Oregon. (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. (h) 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 the medical programs in subsection (g)(A) of this section 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. Prior to a termination of developmental disabilities services, the CDDP must send a Notice of Redetermination (form 5101), provide 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 the performance qualifications and training expectations for determining eligibility for developmental disabilities services 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 an individual’s 18th birthday 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 a valid FSIQ result 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 and developmental history supports eligibility. If an individual has a valid 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 result 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 result of 71-75, verification of an intellectual disability requires all of the following: (i) The individual must have significant impairment in adaptive behavior as measured by an assessment of adaptive behavior, completed by a licensed clinical or school psychologist. (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 disorder, sensory impairment, motor impairment, substance use, personality disorder, learning disability, or Attention Deficit Hyperactivity Disorder (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 an individual’s 22nd birthday 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. Evidence of an other developmental disability must include commonly accepted tests or medical evidence of the condition, and clinical rationale or impression. 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 on an adaptive assessment, 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 Adaptive Behavior Assessment System (ABAS) or Adaptive Behavior Evaluation Scale (ABES) two standard deviations below the mean. (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 standard composite or standard 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 disorder, sensory impairment, motor impairment, substance use, 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; or (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; and (C) Co-occurring conditions do not primarily contribute to significant impairment of adaptive behavior as described in sections (3) and (4) of this rule. (c) 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. (d) 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. (e) 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) are provisional and must be based on documentation that is no more than one year from the date of the application. (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 application, a medical statement by a licensed medical practitioner confirming 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. (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 (v) Social. (C) The impairment, condition, or syndrome cannot be primarily attributed to other conditions including, but not limited to, a mental disorder, sensory impairment, motor impairment, substance use, personality disorder, learning disability, or ADHD. (D) The condition and impairment must continue, or be expected to continue, indefinitely. (b) REDETERMINATION OF ELIGIBILITY FOR EARLY CHILDHOOD. (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 (a)(A)(i) of this section, must be completed no later than the child’s 9th birthday. (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 (a)(A)(ii) of this section, must be completed no later than the child’s 7th birthday. (B) Any time there is evidence that contradicts an eligibility determination, the Department or the Department’s designee may redetermine eligibility or obtain additional information, including securing an additional evaluation for clarification purposes. (C) The CDDP must notify a child and their legal representative 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 application. (e) REDETERMINATION OF ELIGIBILITY FOR SCHOOL-AGED CHILDREN. (A) Any time there is evidence that contradicts an eligibility determination, the Department or the Department’s designee 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 their legal representative 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, motor, substance use. or learning disorders. (ii) If an individual has additional medical, mental, or substance use 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) For applicants less than 22 years of age, documentation no more than three years old from the date of application. (B) For applicants age 22 and older, information obtained after the individual’s 17th birthday, and if current documentation exists, it must be considered. (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 adult 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 FOR ADULTS. (A) Any time there is evidence that contradicts an eligibility determination, the Department or the Department’s designee 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 their legal representative, 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 DEVELOPMENTAL HISTORY. (a) Attempts must be made to collect all records required in section (1) of this rule, including information of developmental history as defined in OAR 411-320-0020. If records exist, they must be considered. (A) When there is no developmental history on record, current documentation may be used if: (i) There is no evidence of head trauma; (ii) There is no evidence or history of significant mental disorder; or (iii) There is no evidence or history of substance use. (B) If there is evidence that the individual was able to function independently, or at a higher level in the past, this information must be considered. Any loss of skills cannot be due to a: (i) Head injury that happened after age 22; or (ii) A mental or substance use disorder. (b) If there is evidence or a history of head trauma, significant mental disorder, or substance use disorder, then a clinical diagnostic impression by a qualified professional must be obtained and include: (A) A detailed description of the individual’s functional experience across their lifespan, including the developmental years; and (B) Consistent evidence to support the decision; and (C) Objective findings that reasonably demonstrate: (i) The individual experienced the condition and significant impairment prior to: (I) Age 18 for an intellectual disability; or (II) Age 22 for a developmental disability. (ii) Lifelong impairments are directly related to the intellectual or developmental disability and not primarily related to a head trauma, significant mental disorder or substance use. (10) SECURING EVALUATIONS. If an eligibility specialist has exhausted all local resources to secure the necessary evaluations for an eligibility determination, the Department or the Department’s designee 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) When a referral is received, the CDDP must complete an intake interview within 30 calendar days, unless more time is needed by the individual or their legal representative. (b) The CDDP must collaborate with the individual or their legal representative to gather historical records related to the individual’s intellectual or an other developmental disability during the eligibility process to complete an application for services. (c) The CDDP must review documents and complete necessary actions relating to timely decisions within 30 calendar days from the receipt of the application and related documents. The CDDP must review the documents, at a minimum, every 30 days thereafter to identify if a determination may be made under sections (3) through (8) of this rule. (d) During the eligibility process, the CDDP must gather enough documentation in order to accept a completed application for developmental disabilities services within 90 calendar days from the date of intake, except in the following circumstances: (A) The CDDP is unable to obtain a complete application because the individual or their legal representative 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 individual’s legal representative. (e) Upon receipt of the completed application, the CDDP must make an eligibility determination unless the following applies and is documented in progress notes: (A) The individual or their legal representative voluntarily withdraws the application; (B) The individual dies; or (C) The individual cannot be located. (f) The CDDP may not use the time frames established in subsection (d) 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: (a) Date of interaction. (b) Referral source to the CDDP. (c) Intake. (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 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 their legal representative may request a hearing as described in OAR 411-318-0025 if the individual or their legal representative disagrees with the eligibility determination or redetermination made by the CDDP. (15) TRANSFER OF ELIGIBILITY. 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, or their legal representative, 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 obtain and retain copies of the following documents: (A) Application. (B) Statement of eligibility determination. (C) Notification of eligibility determination. (D) Evaluations and assessments supporting eligibility. (c) In the event that the items in subsection (b) 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 system. (d) 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. (e) If an individual submits an application for developmental disabilities services and another CDDP terminated services within the past 12 months, as described in OAR 411-415-0030, the eligibility determination from the other CDDP must transfer as outlined in this section. If a redetermination was missed, as described in section (1)(f)(B) of this rule, the redetermination must be completed by the receiving CDDP.