Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB PART: ENHANCED DEVELOPMENTAL DISABILITY SERVICES › Section 16.03.10.501 - DEVELOPMENTAL DISABILITY DETERMINATION STANDARDS: ELIGIBILITY

Current through August 31, 2023
The definitions and standards in the table below must be used
				  to determine whether a participant meets criteria as a person with a
				  developmental disability under Section
				  66-402, Idaho Code.
TABLE 501 - DEVELOPMENTAL
								DISABILITY DETERMINATION STANDARDS
Definition
Standards
"Developmental Disability" means a chronic
								disability of a person that appears before the age of 22 years
								and:
Age of 22 means through the day before the
								individual's 22nd birthday. AND
(a) is attributable to an impairment, such as an
								intellectual disability;
"Is attributable to an impairment" means that there
								is a causal relationship between the presence of an impairing condition and the
								developmental disability.
Age 5 through Adult:
There is a
								presumption that an intellectual disability exists when a full scale IQ score
								up to 75 exists. (IQ of 70 with a standard error of measurement of 5
								points.)
Birth to Age 5:
An IQ test score is
								not required below the age of 5. In these cases it may be necessary to rely on
								the results of a functional assessment. There is a presumption that an
								intellectual disability exists when there is a standard score of 75 or below or
								a delay of 30% overall.
cerebral palsy;
Medical Diagnosis that requires
								documentation.
epilepsy;
Medical Diagnosis that requires documentation. On
								medication controlled or uncontrolled. Does not include a person who is
								seizure-free and not on medication for 3 years.
autism;
Includes the diagnosis of pervasive developmental
								disorder.
or other condition found to be closely related to
								or similar to one of these impairments that requires similar treatment or
								services;
For related or similar conditions, documentation
								must be present to show the causal relationship between the impairing condition
								and the developmental disability. (Does not include mental illness)
Intellectual Disability:
A full scale
								IQ score above 75 can in some circumstances be considered a related or similar
								condition to an intellectual disability when additional supporting
								documentation exists showing how the individual's functional limitations make
								their condition similar to an intellectual disability.
Cerebral Palsy:
Conditions related or
								similar to cerebral palsy include disorders that cause a similar disruption in
								motor function.
Epilepsy:
Conditions related or
								similar to epilepsy include disorders that interrupt consciousness.
or is attributable to dyslexia resulting from such
								impairments; and
AND
(b) results in substantial functional limitations
								in three (3) or more of the following major life activities:
"Results in" means that the substantial limitation
								must be because of the impairment. A "substantial" limitation is one in which
								the total effect of the limitation results in the need for a "combination and
								sequence of special interdisciplinary, or generic care, treatment or other
								services that need to be individually planned and coordinated." Listed below
								are standards for substantial functional limitations in each major life
								area.
Age 3 through Adult:
A score of 2
								standard deviations below the mean creates a presumption of a functional
								limitation.
Birth to Age 3:
The following criteria
								must be utilized to determine a substantial functional limitations for children
								under 3:
a.
The child scores 30% below age
								norm; or
b.
The child exhibits a 6 month delay;
								or
c.
The child scores 2 standard
								deviations below the mean.
self care;
Adult:
A substantial functional
								limitation is manifest when the person requires physical or non-physical
								assistance in performing eating, hygiene, grooming, or health care skills, or
								when the time required for a person to perform these skills him/her self is so
								substantial as to impair their ability to conduct other activities of daily
								living or retain employment.
Birth to Age 21:
A functional
								limitation is manifest when the child's skills are limited according to
								age-appropriate responses such that the parent, caregiver, or school personnel
								is required to provide care that is substantially beyond that typically
								required for a child of the same age (such as excessive time lifting,
								diapering, supervision).
receptive and expressive language;
Age 3 through Adult:
A substantial
								functional limitation is manifest when a person is unable to communicate
								effectively without the aid of a third person, a person with special skills, or
								without an assistive device (such as sign language).
Birth to Age 3:
A substantial
								functional limitation is manifest when they have been diagnosed by a qualified
								professional who determines that the child performs 30% below age norm
								(adjusted for prematurity up to 2 years) or demonstrates at least 2 standard
								deviations below the mean in either area or 1 1/2 below in both areas of
								language development.
learning;
Birth through Adult:
A substantial
								functional limitation is manifest when cognition, retention, reasoning, visual
								or aural communications, or other learning processes or mechanisms are impaired
								to the extent that special (interventions that are beyond those that an
								individual normally needs to learn) intervention is required for the
								development of social, self care, language, academic, or vocational
								skills.
mobility;
Adult:
A substantial functional
								limitation is manifest when fine or gross motor skills are impaired to the
								extent that the assistance of another person or an assistive device is required
								for movement from place to place.
Birth to Age 21:
A substantial
								limitation would be measured by an age appropriate instrument that compares the
								child's skills for postural control and movement and coordinated use of the
								small muscles with those skills expected of children of the same
								age.
self-direction;
Adult:
A substantial functional
								limitation is manifest when a person requires assistance in managing their
								personal finances, protecting their self interest, or making decisions that may
								affect their well being.
Birth to Age 21:
A substantial
								limitation is manifest when the child is unable to help themself or cooperate
								with others age appropriate assistance to meet personal needs, learn new
								skills, follow rules, and adapt to environments.
capacity for independent living; or
Adult:
A substantial functional
								limitation is manifest when, for a person's own safety or well-being,
								supervision or assistance is required, at least on a daily basis, in the
								performance of health maintenance, housekeeping, budgeting, or leisure time
								activities and in the utilization of community resources.
Birth to Age 21:
A substantial
								limitation would be measured by an age-appropriate instrument that compares the
								child's personal independence and social responsibility expected of children of
								comparable age and cultural group.
economic self-sufficiency; and
Adult:
A substantial functional
								limitation is manifest when a person is unable to perform the tasks necessary
								for regular employment or is limited in productive capacity to the extent that
								their earned annual income, after extraordinary expenses occasioned by the
								disability, is insufficient for self-support.
Age 5 to Age 21:
Use the
								pre-vocational area of a standardized functional assessment to document a
								limitation in this area.
Birth to Age 5:
A substantial
								limitation in this area is evidenced by the child's eligibility for SSI, early
								intervention, or early childhood special education under the Individuals with
								Disabilities Education Act (IDEA).
AND
(c) reflects the needs for a combination and
								sequence of special, interdisciplinary or generic care, treatment or other
								services that are of life-long or extended duration and individually planned
								and coordinated.
Age 5 through Adult:
Life-long or
								extended duration means the developmental disability is one that has the
								reasonable likelihood of continuing for a protracted period of time, including
								a reasonable likelihood that it will continue throughout life.
Birth to Age 5:
The expected duration
								may be frequently unclear. Therefore, determination of eligibility by a
								multi-disciplinary team for early intervention services through SSI, an IFSP,
								child study team or early childhood special education services through an IEP
								will be an indicator of this criteria.
(3-17-22)