Pennsylvania Department of Public Welfare -
Medicaid Waivers

It is the policy of the Office of Developmental Programs (ODP), formerly the Office of Mental Retardation, to use the following criteria to determine eligibility for mental retardation services and supports in accordance with 55 Pa. Code § 4210.101:

§4210.101a Clarification of eligibility determinations - Statement of Policy

A. The essential feature of Mental Retardation is significantly subaverage general intellectual functioning that is accompanied by significant limitations in adaptive functioning in at least two of the following skill areas: communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health, and safety. The onset must occur before the individual's 22nd birthday.

1. Except as specified in (b)(2) below, significantly sub-average general intellectual functioning shall be determined by a standardized, individually administered, intelligence test in which the overall full scale IQ score of the test and of the verbal/performance scale IQ scores are at least two standard deviations below the mean taking into consideration the standard error of measurement for the test. The full scale IQ shall be determined by the verbal and performance IQ scores.

2. Diagnosis of mental retardation is made by using the IQ score, adaptive functioning scores, and clinical judgment when necessary. Clinical judgment is defined as reviewing the person's test scores, social and medical history, overall functional abilities, and any related factors to make an eligibility determination. Clinical judgment is used when test results alone cannot clearly determine eligibility. The factors considered in making an eligibility determination based on clinical judgment shall be decided and documented by a licensed psychologist, a certified school psychologist, a physician, or a psychiatrist. In cases where individuals display widely disparate skills or achieve an IQ score close to 70, clinical judgment should be exercised to determine eligibility for mental retardation services.

3. If eligibility cannot be determined through a review of the individual's record and social history, any necessary testing (e.g., adaptive functioning) shall be completed by a licensed psychologist, a certified school psychologist, a physician, or a psychiatrist. This includes determining the eligibility for an individual who is 22 years of age or older, has never been served in the mental retardation service system, and has no prior records of testing. Clinical judgment may be used to determine whether the age of onset of mental retardation occurred prior to the individual's 22nd birthday.

B. Everyone can be evaluated or assessed.

1. Standard tests with adaptations for the individual's visual, motor, and language impairments are available and valid. Other efforts to adapt the IQ test to the individual's particular visual, motor, and/or language impairments must be described and documented.

2. Developmental scales may be used for people who do not or cannot participate in testing. The use of these scales reflects a necessity to use scoring matrices for populations outside the sample used to develop the normative data. They should only be used when no other standard testing technique is available.

C. Genetic conditions and syndromes defined by particular physical features or behaviors such as Klinefelter syndrome are not, by themselves, sufficient to qualify for a mental retardation eligibility determination.

D. The policy for legal and illegal aliens is indicated below:

1. Citizenship is not an eligibility requirement for receipt of mental retardation services and supports in Pennsylvania. The only distinction in this matter is between those who are lawfully in this country (both citizens and aliens) and those who are here unlawfully (illegal aliens).

2. Illegal aliens are not eligible for the Medicaid Program unless an emergency medical condition is present (42 U.S.C.A. §1396b(v)). Counties are not required to provide mental retardation services for illegal aliens.

E. An individual who is currently eligible for mental retardation services will remain eligible for mental retardation services unless eligibility testing indicates otherwise.

F. An individual moving into Pennsylvania from another location will receive a mental retardation eligibility determination for mental retardation services based on the clarification described in this statement of policy.

G. Except for waiver services, appeals from a denial of eligibility follow the county administrative process designed for appeals under the Local Agency Law (2 Pa. C.S. §§551-555) and appealing through the courts. The Local Agency Law is a state law governing procedures for appeals of local agency determinations.

H. Fiscal issues, such as access to testing and payment for testing, should be referred to the appropriate Office of Developmental Programs Regional Office for resolution.

Questions: For questions on eligibility you may call the ODP Customer Service Number.

PA DPW

Last update: July 2, 2007