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COMBINED MANUAL

ISSUE DATE 09/2016

SPECIAL MEDICAL CRITERIA

0011.36

Community Alternative Care (CAC) Targets people at risk of long term or frequently recurring hospitalization (initially designed to serve medically fragile children). They must meet ALL of the following:

- Be under 65 at the time of assessment.

- Be certified disabled by the Social Security Administration or State Medical Review Team (SMRT).

- Be eligible for Medical Assistance.

- Have an interdisciplinary team assessment which determines he/she would require frequent or continued hospitalization without waiver services.

Traumatic Brain Injury Waiver (TBIW) TBIW targets 2 groups of people:

1. Those at risk of the level of care provided in a neurobehavioral hospital.

AND 2. Those at risk of the level of care provided in a specialized nursing facility (designed for people who have cognitive and/or behavioral issues).

They must meet ALL of the following

- Be under 65 at the time of screening.

- Be certified disabled by the Social Security Administration or the State Medical Review Team (SMRT).

- Be eligible for Medical Assistance.

Developmental Disabilities (DD) Waiver Targets people who are determined to have DD and are at risk of the level of care provided in an Intermediate Care Facility for people with developmental disabilities (ICF/DD).

They must:

- Have developmental disabilities as evidenced by substantial limitations in present functioning manifested by significantly sub-average intellectual functioning (generally, full scale IQ score of 70 or less) and commensurate demonstrated deficits of adaptive behavior. These conditions must be manifested before age 22.

OR - Require a 24 hour plan of care that involves a general need for a continuous program which includes aggressive, consistent implementation of specialized and generic training, treatment and services in the areas of adaptive daily living skills, household management, communication, social skills, community living and responsibility for health and safety.

OR - Be assessed as eligible on an age appropriate level by an intake worker or case manager.

Elderly Waiver (EW) Targets people over the age of 65 who are in a nursing facility or at risk of placement in a nursing facility.

Each of the waivers serves both people moving from an institutional setting to the community and people who are determined to be "at risk of" the level of care provided in the respective institutional setting.

CADI, TBIW, and CAC recipients may remain on the waiver after age 65 if warranted by their needs and service plan.

● SEVERE EMOTIONAL DISTURBANCE (SED) There is a child or children in the household who meet the following definition of “severe emotional disturbance” as determined by a qualified professional such that he/she: