Current through Register Vol. 54, No. 44, November 2, 2024
(a)
Eligibility for assessment. The Division will review an
application for enrollment in HIP to determine whether the applicant is
eligible for an assessment, as follows:
(1)
General criteria . An applicant shall be eligible for an
assessment only if all of the following requirements are met:
(i) The applicant sustained a TBI after July
2, 1985.
(ii) The applicant is a
citizen of the United States and was domiciled in this Commonwealth at the time
of the injury and at the time of application for enrollment in HIP.
(iii) The applicant is 21 years of age or
older.
(iv) The application is
completed and is accompanied by the documentation that is requested to verify
the applicant's satisfaction of the eligibility criteria in this
subsection.
(v) The applicant's
alternative financial resources are at or below 300% of the Federal Poverty
Income Guidelines.
(A) The applicant's income
will be assessed using the applicant's most recent Federal Income Tax form,
which the applicant shall provide. If that form is unavailable, the Division
may request other documentation of income. If the most recent Federal Income
Tax form is not representative of the applicant's income at the time of
application, the applicant may submit documents to that effect in support of
the application.
(B) The applicant
shall provide, on forms provided by the Division, information about any court
award or financial settlement made or pending as a result of the TBI, and any
other funds which are available to the applicant. If all or part of the award,
settlement or other funds is unavailable to the applicant to use for HIP
services, the applicant may submit documents to that effect in support of the
application.
(2)
Condition criteria. An
applicant shall be eligible for an assessment only if the applicant's
impairment is not the result of one or more of the following conditions:
(i) Cognitive or motor dysfunction related to
congenital or hereditary birth defects.
(ii) Putative birth trauma or asphyxia
neonatorum (hypoxic-ischemic-encephalopathy).
(iii) Hypoxic encephalopathy unrelated to
TBI.
(iv) Significant preexisting
psychiatric, organic or degenerative brain disorder.
(v) Stroke.
(vi) Spinal cord injury in the absence of
TBI.
(3)
Symptom
criteria. An applicant shall be eligible for an assessment only if the
applicant does not manifest any symptom, such as a comatose condition, which
would prevent the applicant from participating in the assessment in a
meaningful way or prevent the provider from doing a full and complete
assessment.
(4)
Assignment
agreement. An applicant shall be eligible for an assessment only if
the applicant or authorized representative completes an assignment agreement
which, conditioned upon the applicant's receipt of HIP services, would assign
to the Department rights in future court awards, insurance settlements or any
other proceeds which have accrued or will accrue to the applicant as a result
or by virtue of the applicant's TBI, up to the amount expended for HIP services
on behalf of that individual.
(b)
Assessment process. The
Division will refer an applicant who is eligible for an assessment to a
provider. The provider shall assess the applicant for the following:
(1) To corroborate the Division's
determination that the applicant satisfies the condition and symptom criteria
in subsection (a)(2) and (3).
(2)
To determine that the applicant has the physical, social, cognitive,
psychological and vocational potential for useful and productive activity which
can be nurtured by rehabilitation services available through HIP so as to
enable the applicant to progress toward a higher level of functioning and
transition to a less restrictive environment.
(3) To determine that the applicant has needs
that can be addressed by HIP services, that will not be addressed by any other
services to which the applicant is entitled.
(4) To determine that the applicant does not
manifest suicidal or homicidal ideation, or potentially harmful aggressive
behavior, to such a degree that HIP cannot provide the appropriate services
through its providers to sufficiently address these ideations or
behaviors.
(c)
Forms and procedure. The provider shall complete the
assessment on forms provided by the Division. A provider conducting an
assessment shall:
(1) Review the applicant's
medical records.
(2) Review all
pertinent documentation submitted by physicians on behalf of the
applicant.
(3) Evaluate the
applicant's ability to benefit from rehabilitation services, performed in
accordance with standards prevailing in the field.
(d)
Development of rehabilitation
service plan. If the provider corroborates the Division's initial
determination under subsection (a)(2) and (3), and determines that the
applicant meets the criteria in subsection (b)(2)-(4), the provider shall
develop a rehabilitation service plan for the applicant as specified in §
4.8 (relating to rehabilitation
service plan).
(e)
Assessment period. The provider shall complete its assessment
and give written notification of its determination to the Division and the
applicant or authorized representative within 14 days after the provider begins
to conduct an assessment of the applicant. If the provider determines that the
applicant is eligible for enrollment in HIP, the provider shall also complete a
rehabilitation service plan for the applicant within that 14-day
period.
(f)
Reapplication. If the Division determines that an individual
is not eligible for an assessment or that an applicant is not eligible for
enrollment in HIP after an assessment has been completed, the individual may
repeat the process for seeking enrollment in HIP when the individual or
authorized representative believes that the factors which rendered the
individual ineligible for enrollment in HIP have been eliminated.
This section cited in 25 Pa. Code §
4.7 (relating to
enrollment).
