SFY 2012

Health and Human Services Eligibility and Service Fact Book

Table1:DemographicComparisonofRI,CTandMA
Population2010 MedianIncome Familyofthree 2/2010 PercentinPoverty Atorbelow 100%FPL Children18 Adults1864 Elders65and older PercentChangein SNAPParticipation 20072010 Percentof PopulationSSI Beneficiaries2009 SSIw/disabilitiesas %oftotalpop UnemploymentRate February2010 February2011 RateofUninsurance 2010 BudgetShortfallSFY 12 InDollars %SFY2011 Budget RhodeIsland 1.05M $73,619 12%(Individuals) 8%(Families 24% 16% 13%
[19%oftheseareolderthan 75]

Connecticut 3.52M $84,873 9%(Individuals) 7%(Families) 15% 12% 9%

[11%oftheseareolderthan 75]

Massachusetts 6.60M $82,883 10%(Individuals) 7%(Families) 20% 14% 11%

[12%oftheseareolder than75]

22% 19%totalpop. 94%Age65 2.7% 11.8% 1 11.2% 12% YES $331,100,000 10%

17% 17.4%totalpop. 94%Age65 1.4% 9.2% 9.0% 16% YES $3,700,000,000 28%

10% 17%totalpop. 89%Age65 2.1% 8.7% 8.2% 5% YES $1,800,000,000 5.7%

Sources include: cbpp.org/cms/:statehealthfacts.org; census.gov; socialsecurity.gov/policy/docs; ctkidslink.org/pub/

Table2:Medicaid/CHIP:ComparisonofRI,CTandMABy Population SFY2009

RhodeIsland 1 $246 $369 $1,787 $2,057 $1,435 0 $729 $926 59% 175,061 16.6% $1,702,972,284 24.5% Connecticut 2 $246 $309 $2,096 $2,110 $1,633 0 $801 $1,112 51% 455,133 12.9% $6,035,281,239 25.2% Massachusetts 3 $292 $345 $949 $1,467 $1,038 $84 2 $691 $1,223 54% 1,177,922 17.9% $12,480,644,429 26.3%

PerMemberPer Month(PMPM) Children Parents/Adults Adults w/Disabilities Elders Children w/SpecialNeeds PersonalCare AveragePMPM MandatoryEligibles AveragePMPM OptionalEligibles PercentofEnrollees MandatoryEligible TotalAverage Enrollment Enrollmentas%of StatePopulation TotalProgram SpendingAllFunds Spendingas%of TotalStateBudget

1 2

Source: RI Medicaid Annual Expenditure Report. Source: State Budget Review and Analysis 200902100 at: ct.gov/opm ctkidslink.org/ub_details_506.html\ 3 Source: MassHealth Summary Report at: mass.gov/eohhs/masshealth/

Table3:RIMedicaidSFY2010 Mandatoryv.OptionalPopulations FederalMandatoryPopulations OptionalPopulations

Enrollees:105,559 TotalExpenditures:$960,920,647 Enrollees:77,148 TotalExpenditures:$875,184,003

RecipientsofSupplementalSecurity Income(SSI)orSupplementalSecurity DisabilityInsurance(SSDI) LowincomeMedicarebeneficiaries; Familieswithincomeupto1996AFDC Standard110%FPL Childrenunderagesixandpregnant womenwithfamilyincome133%FPL InfantsborntoMedicaidenrolled pregnantwomen; Childrenwhoreceiveadoption assistanceorwholiveinfostercare, underafederallysponsoredTitleIVE program. Personsmeetingthefinancialand eligibilityrequirementsforan institutionallevelofcare:hospital, nursingfacilities,orICF/MR

NonSSIeldersoradultswithdisabilities withincomefrom74%100%FPL AgedandPersonswithDisabilities receivingHomeandCommunityBased Serviceswithincomeupto$300%SSI level($2022permonth) Childrenuptoage6withfamilyincome from133250%FPL Childrenage619withincomefrom133 250%FPL Parentsinfamilieswithincome175% Individualsdeterminedtobemedically needyduetolowincomeandresources ortolargemedicalexpenses Childrenunder18withadisabling conditionsevereenoughtorequire institutionalcare,butwholiveathome (theKatieBeckettprovision)with income250%FPL WomeneligibleforBreastandCervical Cancerprogram

Table4a:RIMedicaidSFY2010 ExpendituresforMandatoryv.OptionalPopulations NumberofEnrolleesandPerMemberAnnually

Population/Delivery System
ChildrenRIteCare/RIte Share NumberEnrollees AnnualCost ParentsRIteCare/RIte Share NumberEnrollees AnnualCost

Mandatory
133%FPL 3 (or$2,054) 4 59,906 $3,444 110%FPL (or$1,558) 7,615 $7,744

Optional
133250%FPL 5 (or$2,0543,860) 21,948 $2,494 110175%FPL (or$1,5581,702) 34,491 $4,108

Total
81,854 $3,189 42,106 $4,766

74100%FPL Adultsw/Disabilities SSIRecipient (or$671907.50) PrimaryCareRhodyHealth Income74%FPL 300%SSIHCBS orConnectCareChoice (or$671) 6 (or$2,022permo.) LTCInstitutionalandHCB MedicallyNeedy services 30,542 10,688 41,233 NumberEnrollees $19,615 $29,940 $22,292 AnnualCost EldersPrimaryCare SSIRecipient 74100%FPL (Medicare,Nondualsin 74%FPL (or$671907.50) RhodyHealthorConnectCare (or$671) 300%SSIHCBS Choice) (or$2,022permos.) LTCInstitutionalandHCB MedicallyNeedy services 7,396 10,021 17,417 NumberEnrollees $13,056 $35,798 $26,141 AnnualCost Childrenw/SpecialNeeds SSI,FosterCare, KateBeckettchild RiteCare/RiteSharefor AdoptionSubsidy, 250%FPL FosterKids,SSI&Adoption PediatricNursing (or$2,269) Subsidy;KatieBeckettFeefor Facility Service 10,030 2,732 12,403 NumberEnrollees $17,040 $15,253 $16,698 AnnualCost TotalNumberEnrollees 105,459 77,148 182,608 TotalAverageAnnualCost $9,112 $11,344 $10,055 TotalExpenditures $960,920,647 $875,184,003 $1,863,000,000 FederalFundsforCostsNot OtherwiseMatchable $17,800,000 (CNOM)UnderMedicaid Source:DerivedfromMMISdatapreparedfortheSFY2010RIMedicaidAnnual

ExpenditureReport

Table5:RIMedicaidSFY2010 Mandatoryv.OptionalServices FederalMandatoryServices Optional/WaiverServices

Expenditure:$1,294M Expenditure:$542M AcuteCare AcuteCare Physiciansservices Rehabilitationandothertherapies Laboratoryandxrayservices Prescriptiondrugs Inpatienthospitalservices Medicalcareorremedialcarefurnished Outpatienthospitalservices byotherlicensedpractitioners Early&periodicscreening,diagnostic Clinicservices andtreatmentservices(EPSDT)for Dentalservices,dentures individualsunderage21 Prostheticdevices,eyeglasses,DME FamilyPlanningandsupplies Primarycarecasemanagement Federallyqualifiedhealthcenter TBrelatedservices (FQHC)services Otherspecialistmedicalorremedialcare Ruralhealthclinicservices Nursemidwifeservicestotheextent InstitutionalServices permittedbyStatelaw Intermediatecarefacilityservicesforthe Servicesofcertifiedpediatricand mentallyretarded(ICF/MR) familynursepractitionerstotheextent Inpatient/nursingfacilityservicesfor theyareauthorizedtopracticeunder individuals65andoverinaninstitution Statelaw formentaldiseases Inpatientpsychiatrichospitalservicesfor InstitutionalServices individualsunder21 Nursingfacilityservicesforindividuals 21andolder HomeandCommunityBasedServices HomeandCommunityBasedWaiver HomeandCommunityBasedServices Services Homehealthcareservicesforany Otherhomehealthcare individualentitledtonursingfacility Targetedcasemanagement care Respiratorycareservicesforventilator dependentindividuals Personalcareservices HospiceServices ServicesfurnishedunderaPaceProgram

Table5a:RIMedicaid PotentialImpactofChangesinOptionalPopulationsandServices AllowedUnderFederalHealthCareReform 7 (PenaltyforNoncomplianceislossofFMAP)

OptionalPopulation/MOE 8 Parents 110175%FPL Statemayrequesthardship waiverandreduceeligibilityto 133%FPLfor18months MajorOptional&Waiver ServicesExpenditures SFY2010 10 BehavioralHealth 11 Person/ProviderImpact Ifwaiverisapproved: Eligibilityloweredto133%FPL (or$2,054) 6,643parentslosecoveragefor18 months 9 Wouldsignificantlyreducebehavioral healthservicesforadults1964andfor childrenandeldersincertainsetting.May reduceproviderrevenuesbyupto60% CMHC,InpatientPsych. Eliminatesallservicesforallpopulations inbothacuteandlongtermcaresettings. EstimatedFiscalImpact SFY1213(18mos) $15,100,000(F) $14,100,000(GR) $29,687,000(AllFunds)

$58,786,481(F) $39,645,232(GR) $111,325,025(AllFunds) $5,962,804(F) $5,294,142(GR) $11,256,947(AllFunds) $36,242,074(F) $32,177,926(GR) $68,420,000(AllFunds) $107,405,337(F) $95,361,015(GR) $202,766,353(AllFunds) $42,948,076(F) $38,131,924(GR) $81,080,000(AllFunds) $14,391,245(F) $12,777,425(GR) $27,168,671(AllFunds) SFY12 $20,100,000(F) $18,700,000(GR)* *Onlyifstateprograms eliminated

Dental Elders&DisabledHCBS 12

Servicesandsupportsenablingboth populationstoremaininthecommunity wouldbeeliminated.Nursinghomecare utilizationwouldincrease MR/DDincludesHCBS(group WouldeliminateMR/DDservicesboth homesandsharedliving)and institutionalandinthecommunitybased InstitutionalICF/MR settingaswellasalllongtermcare (Zambarano) servicesnotcoveredinstateplan Pharmacy Allpharmacyisoptionalservicein Medicaid.Benefitcouldbelimitedrather thaneliminated,however. OutpatientServices Reductionsinservicesextendtoclinic basedandcommunitytreatmentsettings andhospice. 13 CNOM UnderGlobalWaiver,anyreductionsin Stateisrequiredtoextend eligibilityforoptionalpopulationsresults Medicaidcoverageintomanyof ineliminationofCNOM.Statemaynotbe individuals133%FPLcovered abletomaintainGRprogramsnowfunded byCNOMsin2014 byCNOM.

Source: MMIS data prepared for the SFY 2010 Medicaid Annual Expenditure Report

Table6:PubliclyFundedHealthCoverage:Comparison:ofRI,CTandMA 14 Legend:SF=statefundedSS=Statesubsidized;LBP=limitedbenefitpackage
*FPL=2011federalpovertylevelindollars,permonth(pm)forfamilyof3

RhodeIsland
250%FPL (or$3,088) 175%FPL (or$2,702) 250%FPL 19 (or$3,088) 250%FPL (or$3,088) None

Connecticut
300%FPL 15 (or$4,633) 185%FPL (or$2,857) 185300%FPL(SF)(LBP) 17 (or$2,8574,633) 250%FPL (or$3,088) 300%FPL (or$4,633) 5868%FPLnoSSI(LBP) 21 (or$8961,050) 68%&Up(SF)(LBP) 22 ($1,050up) 5868%FPL (or$8961,050) 68%FPLto300%SSIif HCBSeligible (or$1,0502,022) $1600Individual $2400Couple 25 $476576Individual $634734Couple 28 $1600Individual $2000Couple

Massachusetts
300%FPL 16 (or$4,633) 133%FPL (or$2,054) 133300%FPL(LBP) 18 (or$2,0544,633) 300%FPL (or$4,633) 300%FPL (or$4,633) 133300%FPL(LBP) 23 (or$2,0544,633)

1.Childrenage19 2.Parents

3.PregnantWomen 4.LegalPermanent ResidentChildren 20 5.OtherNon DisabledAdults Underage64 6.Aged,Blindand Disabled: Eligibility 24 ResourceLimit

100%FPL (or$1,544) $4000Individual $6000Couple

OverAge65100%FPL (or$1,544) UnderAge65133% 26 (or$2,054) Overage65Only: $2000Individual $3000Couple $903or$1200 29 Individual $1215or$1615 30 Couple $2000Individual $3000Couple

7.Medically Needy 27 MonthlyIncome Limit2010 ResourceLimit

$903Individual $1215Couple $4000Individual $6000Couple

Table6:PubliclyFundedHealthCoverage:Comparison:ofRI,CTandMA 14 Legend:SF=statefundedSS=Statesubsidized;LBP=limitedbenefitpackage
*FPL=2011federalpovertylevelindollars,permonth(pm)forfamilyof3

RhodeIsland
KBStatePlan NoLimitations 18 250%FPL(ChildOnly) (or$2,269)

Connecticut
KBWaiver EnrollmentCapped None Upto300%ofSSI (or$2,022)

Massachusetts

8.TEFRAKatie Beckett(KB) Provision 31 AgeLimit FinancialEligibility ClinicalEligibility ResourceLimit 9.LongtermCare FinancialEligibility Clinicaleligibility ResourceLimit

KayleighMulliganWaiver (KBWaiver) 18 Childsincome$60mos. MeetSSIdisabilitycriteria MeetSSIcriteriafora MeetSSIdisabilitycriteria andInstitutionallevelof severedisabilityrequiring foraseveredisability care ICF/MRlevelofcare requiringhospitalor pediatricnursingfacility levelofcare $4000(childonly) $1000 $2000 MedicallyNeedyor MedicallyNeedyor MedicallyNeedyor 300%ofSSI 300%ofSSI 300%ofSSI (or$2,022permos.) (or$2,022permos.) (or$2,022permos.) Institutionallevelofcare, Institutionallevelofcare, Institutionallevelofcare, basedonfunctionalneed basedonfunctionalneed basedonfunctionalneed $2000Individual $2000Individual $2000Individual $4000Couple $4000Couple $4000Couple

Table6:PubliclyFundedHealthCoverage:Comparison:ofRI,CTandMA 14 Legend:SF=statefundedSS=Statesubsidized;LBP=limitedbenefitpackage
*FPL=2011federalpovertylevelindollars,permonth(pm)forfamilyof3

RhodeIsland
MedicallyNeedor 300%ofSSI (or$2,022permo.) Asevere,chronic disabilityofaperson attributabletoamental and/orphysical impairment,manifested beforeage22andis:likely tocontinueindefinitely; resultsinsubstantial functionallimitationsin3 ormoreareasofmajor lifeactivity;and:reflects theneedforspecial, interdisciplinary,or genericcare,treatment,or otherserviceswhichare lifelongorofextended durationandare individuallyplannedand coordinated. 32 $2000Individual $4000Couple

Connecticut
MedicallyNeedor 300%ofSSI (or$2,022permo.) Significantlysubaverage generalintellectual functioningw/deficitsin adaptivebehavior manifestedduring developmentperiod $2000Individual $4000Couple

Massachusetts
MedicallyNeedor 300%ofSSI (or$2,022permo.) Adultsover18withmental retardationorforchildren, underage8,musthave autisticdisorder,Retts, childhooddisintergrative disorder,PDD,orAspergers ANDseverebehavioral, communication,orsocial deficitsinterferingwith abilitytoremaininthe homeorcommunitywereit notforwaiverservices $2000Individual $4000Couple

10.Developmental DisabilityWaiver FinancialEligibility Clinicaleligibility [Seealso accompanying reportbyBurns& Associates,Inc.] ResourceLimit

Table6:EconomicSecurityPrograms:ComparisonofRI,CTandMA SFY2010 RhodeIsland Connecticut Massachusetts

RIWorks 33 EarnedandUnearned $1,832(familyof3) 36 $1000 24monthsinany60mos. timeperiod 48mos. 40 No JobsFirstTemporary FamilyAssistance 34 Gross:<75%StateMedian Income(SMI)$4,153 (1parent/familyof3) $3000 21mos. 39 60mos. SolelyStateFunded (2parentfamilies& personsexemptfromtime limit) 33,551Recipients 17,774Families $423$674 41 4.2% $266,788,107 $183,421,00 (75%ofTotal) TotalBasicAssistance $87,563,184 FromBlockGrant $12,997,800 GeneralRevenue $74,565,435 ChildCare $27,000,000M Administration $18,000,000 Nonassistance $105,000,000 TAFDC 35 Gross:<50%SMI$1,724 37 (familyof3) Net:$1,171Exempt 38 $1,143Nonexempt $2500 Nomorethan24continuous monthsina60mos.Period None SeparateStatefundedProgram (Exemptrecipients) 97,967Recipients 49,863Families $618 8.3% $459,371,116 $358,900,00 (75%ofTotal) TotalBasicAssistance $308,078,000 FromBlockGrant $48,973,000 GeneralRevenue $255,104,000 ChildCare $91,000,000 Administration $14,000,000 Nonassistance $150,000,000

TANF CashAssistance MonthlyIncomeLimit

AssetLimit PeriodicTimeLimit

Statelifetimelimit StateProgram

Number TANF Participants MonthlyBenefit Familyof3 %Changein CaseloadSFY0710 TotalTANFBlock Grant StateMOERequired BasicAssistance Expenditures SFY2010

18,197Recipients 7,875Families $554 37.3% $95,021,587 $64,391,587 (80%ofTotal) 42 TotalBasicAssistance $43,985,118 FromBlockGrant $43,985,118 GeneralRevenue 0 ChildCare $26,0000,000 Administration $9,000,000 Nonassistance $5,000,000

AmountofBlock Grant Transferred/Spent

10

Table6:EconomicSecurityPrograms:ComparisonofRI,CTandMA SFY2010 RhodeIsland Connecticut Massachusetts

CCAP TANFrecipient OR EMPLOYEDandwith income<180% FPL($2,206permonthfor familyof2): TANFmustbeinapproved workplanactivity. Otherwise,parentmust workatleasthalftime NoneforTANF Variesfrom08%income $10,000liquidassetsfor lowincomeonly 6,499 $46,836,783 $39,689,026 $7,147,757 Care4Kids TANFrecipient OR EMPLOYEDand<50% StateMedianIncome(SMI) ($2,879permonthfor familyof2) 43 Workatleasthalftimeor attendapprovedtraining program.Noneforteen parent,caretakerrelative NoneforTANF Upto100%ofstaterate None 14,000 $101,997,000 $91,997,000 $10,000,000 DTA TANF,SSIrecipient,fosterchild OR <50%StateMedianIncome (SMI)($2,793permonthfor familyof2) 44 Workatleasthalftime,work search,maternityleave, education/training,special needschild,homeless,active military,65orolder NoneforTANF Upto10%offamilyincome None 24,800 $389,704,000 $348,682,120 $41,021,880

ChildCare Assistance Eligibility Work/Activity Copays LI=lowincome ResourceLimit SFY2010Average ChildrenServed SFY2010 Expenditures FederalShare StateGeneral Revenue

11

Table6:EconomicSecurityPrograms:ComparisonofRI,CTandMA SFY2010 RhodeIsland Connecticut Massachusetts

SSIEligibleandLivingin: Ownhousehold $40(I) $79(C) Householdofother $52(I) $97(C) TitleXIXfacility $20 AssistedLiving $538 SSIEligibleandLivingin: Independently $168(I) $274(C) TitleXIXfacility $39(I) $78(C) Room&Board Basedoncost SSIEligibleandLivingin: Ownhousehold $114128(I) $180636(C) Householdofother $88374(I) $194215(C) TitleXIXfacility $43(I) $86(C) AssistedLiving $454(I) $681(C) LicensedRestHome $149293(I) $636923(C) 45 SharedLiving $30150(I) $180636(C) 187,359 $222,311,000

OptionalState SupplementtoSSI (I=individual, C=Couple)

TotalAverage Beneficiaries SFY2010 Expenditures

32,050 $22,249,416

10,240 $43,100,001

12

Table6:EconomicSecurityPrograms:ComparisonofRI,CTandMA SFY2010 RhodeIsland Connecticut Massachusetts

GeneralPublic Assistance Hardship19unableto workfor30dueto disability IncomeLimit:$327(I) $449(couple)permos. Assetlimit:$400 BridgeSameasabove, butappliedforSSI.Re paymentrequiredafter SSIawarded 538Bridge 421Hardship Total959 $1,882,920 EmergencyAidtotheElderly, Disabled&Children Unemployableduetoshort Unabletoworkduetophysical termconditionorinneedof ormentalincapacitylastingat transitionalassistance least60days;awaitingSSI pendingdisability determination;caringfor determination disabledperson;ordisabled IncomeLimit: IncomeLimit:TANFlevels $53permos. (homeless);$212 (familyof2) AssetLimit:$250 AssetLimit$250 StateAdministered GeneralAssistance

OtherPublic Assistance

SFY2010Recipients

SFY2010SGR Expenditures

45,000lowincomeadults transferredtoMedicaidin April2010. 12,000remained SFY2009$183,000,000 SFY2010NotAvailable

Notavailable

$84,658,966

13

Historical high MA does not include the pmpm for personal care assistance in monthly spending by population. The $84 pmpm is the average cost pmpm for three populations: adults with disabilities, children with special needs, and elders. The actual amount varies considerably by population from as little as $12 pmpm to as high as $246 for children with special needs living in the community. 3 Poverty Level Children : 0-6 up to 133%; 6-19 100% FPL 4 FPL limit per month for family of three, unless otherwise indicated) 5 Includes children covered under CHIP and CHIRPRS -- State receives enhanced matching rate 6 For SSI recipients and all adults with disabilities and elders, monthly FPL is present for family of one. 7 The MOE provisions in the federal Patient Protection and Affordable Care Act generally ensure that coverage for adults under state Medicaid program remains in place pending implementation of coverage changes that become effective in January 2014. The Medicaid MOE provisions relating to adults expire when the Secretary determines that an Exchange established by the State under section 1311 of the Affordable Care Act is fully operational. The MOE provisions for children under age 19, in both Medicaid and CHIP are effective through September 30, 2019. 8 The MOE provisions in the federal Patient Protection and Affordable Care Act prohibit the states from reducing eligibility for mandatory populations. States may reduce or eliminate optional services for both mandatory and optional populations and limit mandatory services for optional populations, but only in a narrow range of circumstances. 9 If the hardship waiver is approved, the state may be required to restore eligibility to FFY 2010 levels when the exchange is implemented in FFY 2014. Medicaid officials indicated that actual implementation of the roll back can not take effect until the second half of SFY 2012 due to systems challenges. For these reasons, only 18 months of savings is assumed. Note: When eligibility is restored in 2014, parents will be covered at the current, lower, FMAP rate. 10 Waiver includes all optional, non-state plan Home & Community Based Services (HCBS)
2

Includes specialty and rehabilitation services provided through the Community Mental Health Centers (CMHC) and health plans as well as certain in-patient psychiatric services, substance abuse and other community based services 12 Covers personal care, case management, assisted living and an array of other non-state plan services provided to elders and persons with disabilities in non-institutional settings
Under the terms and conditions of the Global Consumer Choice Waiver, any reductions in eligibility will result in the loss of federal CNOM dollars 14 Medicaid/CHIP unless designated as state-funded (SF) or as state subsidized (SS) with the beneficiary paying the remaining costs. Limited benefit package (LBP) means less comprehensive coverage than under full Medicaid. 15 HUSKY B is CHIP funded from 185-300% FPL w/sliding scale premiums. There is a buy-in for kids w/income above 300 FPL 16 State-Subsidized 300% FPL Up (LBP) 17 State-subsidized Buy-in 300-400% FPL (LBP) 18 State-Subsidized 300% FPL Up (LBP) 19 State subsidized Buy-in 250-350% FPL (LBP) 20 CT and RI funded through CHIRPA Special Enhanced Match 21 Only for adults age 19-64 who do not qualify for Supplemental Security Income (SSI) 22 Charter Oak Health Plan available to any uninsured adults for $307 per month regardless of income (LBP) 23 State-Subsidized 300% FPL Up (LBP) 24 FPL adjusted for family size of one. 25 State-Subsidized Buy-in 300-400% FPL; Resource Limit: Same 26 State-Subsidized 133% FPL Up Resource Limit :$2000- Individual $3000-Couple 27 Beneficiarys income exceeds eligibility limits, but has high medical expenses. Once beneficiary spends down to monthly limit, receives Medicaid coverage for all State Plan Services. 28 Amt varies by region
13

11

14

Higher amount if beneficiary qualifies for personal care assistance Higher amount if beneficiary qualifies for personal care assistance 31 Tax Equity and Financial Responsibility Act of 1982 ( TEFRA) gave the states the option of adopting a Katie Beckett waiver or state plan amendment (SPA). The waiver option gives the states the flexibility to implement higher/lower age and income limits, cost-sharing, and waiting lists and to provide a more limited benefit package. The SPA option provides full comprehensive benefits and requires states to cover all state plan services as well as any determined to be medically necessary. The SPA option does not permit enrollment caps or waiting lists. 32 Based on the federal Developmental Disabilities Act of 2002, as amended. 33 Must be engaged in work or job-readiness program 34 Must be engaged in work or job-readiness program 35 Cash assistance while engaged in employment, education, or training related to job permanency. 36 Maximum earned and unearned monthly income limit 37 State Median Income for SFY 2010 $41,396 for family of three. Changed from 85% SMI January 2010 families exempt from the work requirement, gross income for a family of three =$1,171. 38 Exempt recipients not subject to time limits and hardship families. Benefits provided through separate state program funded through Maintenance of Effort (MOE) funds. 39 Six month extensions granted in increments up to lifetime limit if working & income remains <75% SMI; two additional 21 month extensions granted if hardship requirements are met 40 Initial hardship extension of 6 months; with eligibility for additional 6 months 41 Varies by region 42 States are assigned a 70% or 80% Maintenance of Effort (MOE) requirement based on a variety of factors related to historic expenditures, worker participation rates and various credits. 43 Prior to 11/06/10, income limit for employed was 75% of SMI $4,319 per mos for family of two. 44 Families remain eligible until reach $100 of SMI 45 Amt. above varies by aged, blind, disabled eligibility category)
30

29

15

MEMORANDUM

March 29, 2011 To: Craig Stenning From: Peter Burns and Mark Podrazik RE: Comparing State Definitions of ID/DD You recently posed the question as to whether or not the Rhode Island definition of developmental disabilities is more liberal than surrounding States and/or the States in general. This memo has been prepared to explore that question. The background research that was conducted for this memo included a review of federal statutes, regulations and 1915(c) Waiver instructions; the selection of 10 northeastern States 1 for closer examination of statutes, regulations and waivers; and a review of selected publications of the American Association for Intellectual and Developmental Disabilities (AAIDD) and the National Association of Directors of Developmental Disabilities Services (NADDDS). Our research particularly on the 10 northeastern States was primarily focused on the definition of developmental disabilities as it is applied to adults, in as much as the mission of the Division of Behavioral Health, Developmental Disabilities and Hospitals is to provide services to adults in Rhode Island meeting the statutory and regulatory definition of developmental disability. In summary, and as a general conclusion, we believe that Rhode Islands definition of developmental disabilities is in concert with 39 other States; is approximately equivalent to the definition of Maine, New Hampshire, New Jersey, and New York; and broader than the definition used in Connecticut, Delaware, Massachusetts, Pennsylvania and Vermont. The balance of this memo and the Appendices contains the result of our research and is organized into the following sections: federal definitions, a review of the States in general, a discussion of the definition used in the 10 northeastern States, and concludes with a brief discussion of options available to control waiver costs for persons with developmental disabilities in lieu of a change in definition.

The States examined included Connecticut, Delaware, Massachusetts, Maine, New Hampshire, New Jersey, New York, Pennsylvania and Vermont (in addition to Rhode Island)

Federal Definitions The Federal government through the Medicaid program has greatly influenced the definitions adopted by the States relating to mental retardation (and the more current term of intellectual disabilities) and developmental disabilities. There are three particular Federal uses of these terms that have influenced the States: eligibility for services in Intermediate Care Facilities for People with Mental Retardation (ICF/MR), eligibility for Section 1915(c) Waivers, and the Developmental Disabilities Assistance and Bill of Rights Act of 2000. Appendix A contains the definitions used in each of these three instances. The ICF/MR program was added to Medicaid as an optional service in 1971 to provide States with federal funds for institutional programs serving only individuals with mental retardation. The federal definition provided that matching monies would be available for services provided to persons with mental retardation and related constitutions. In 1981 the Medicaid waiver program under Section 1915(c) was authorized to provide matching funds to States for programs that delivered home and community based services (HCBS) as an alternative to ICF/MRs. The eligibility definition for the HCBS waivers was directly tied to the definition used for ICF/MR mental retardation and related conditions and required that the program participants need the level of care provided by ICF/MRs. While federal Medicaid statutes do not define mental retardation 2 , the related conditions criteria are defined through both examples of medical conditions (cerebral palsy or epilepsy) and through functional criteria. The functional criteria in the regulations are:
Persons with related conditions means individuals who have a severe, chronic disability that meets all of the following conditions: (a) It is attributable to (1) Cerebral palsy or epilepsy; or (2) Any other condition, other than mental illness, found to be closely related to mental retardation because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of mentally retarded persons, and requires treatment or services similar to those required for these persons. (b) It is manifested before the person reaches age 22. (c) It is likely to continue indefinitely. (d) It results in substantial functional limitations in three or more of the following areas of major life activity: (1) Self-care. (2) Understanding and use of language. (3) Learning. (4) Mobility. (5) Self-direction. (6) Capacity for independent living.

Though there is broad consensus of the definition of intellectual disability (mental retardation) largely based on the work of AAIDD: Intellectual disability is a disability characterized by significant limitations both in intellectual functioning (reasoning, learning, problem solving) and in adaptive behavior, which covers a range of everyday social and practical skills. This disability originates before the age of 18.

Burns & Associates, Inc.

March 29, 2011

As Zaharia and Moseley (2008) 3 point out, these federal definitions based on the original criteria for ICF/MRs have led States to adopt eligibility criteria that are differentiated by at least two factors a categorical factor that references specific related conditions by medical diagnosis such as mental retardation, spina bifida, autism, etc., or functional criteria such as contained the related conditions definition, or more recently, in the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (2000 Act). The 2000 Act does not contain any specific medical diagnosis as criteria for developmental disabilities; it instead is based on a persons adaptive abilities or capacity to perform tasks at a specific level:
a severe, chronic disability of an individual that(i) is attributable to a mental or physical impairment or combination of mental and physical impairments; (ii) is manifested before the individual attains age 22; (iii) is likely to continue indefinitely; (iv) results in substantial functional limitations in 3 or more of the following areas of major life activity: (I) Self-care. (II) Receptive and expressive language. (III) Learning. (IV) Mobility. (V) Self-direction. (VI) Capacity for independent living. (VII) Economic self-sufficiency; and (v) reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic services, individualized supports, or other forms of assistance that are of lifelong or extended duration and are individually planned and coordinated.

Adding further complexity to the comparativeness of State definitions is the flexibility afforded States under the Section 1915(c) waivers to target specific subgroups of individuals that may be included in the larger population that require the ICF/MR level of care because of their mental retardation or related conditions. This targeting may be based on such things as:

Nature or type of disability; Specific diseases or conditions; Functional limitations (e.g., extent of assistance required in activities of daily (ADLs) and/or instrumental activities of daily living (IADLs); and, Living arrangement (e.g., persons with developmental disabilities who live with their families or in living arrangements where fewer than four persons unrelated to the proprietor reside).

Examples of this targeting include Connecticuts targeting of developmental disability to those individuals who currently reside in general Nursing Facilities. A National View In their 2008 paper Zaharia and Mosely surveyed the States to determine the definitions used for both the ICF/MR and Waiver programs. In all, 47 States participated in the survey
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State Strategies for Determining Eligibility and Level of Care for ICF/MR and Waiver Program Participants

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(unfortunately Rhode Island was not one of them) which allowed the authors to classify and compare the definitions used. Their paper drew the distinction between the categorical (i.e. diagnosis), functional (i.e. the 2000 Act) and the combination approach to definitions. The authors concluded that most States 39 used a combination approach to the definition. Further, the authors found that 16 States used the mental retardation and related conditions definition and 31 States used the 2000 Act definition, although most of these States added a categorical component. Only eight States used the 2000 Act definition (i.e. mental or physical impairment or combination of mental and physical impairments) exclusively. Based on our review of the Rhode Island definition, we suspect that the authors would have included Rhode Island into the group of States that uses the 2000 Act with a categorical component. Table 1 that follows is from the Zaharia and Mosely paper. The States are first classified as to whether they use the mental retardation and related conditions definition that originated with the ICF/MR program or use the Developmental Disability definition from the 2000 Act (also included in this latter category are States that use their own definition that is broader than the mental retardation and related conditions definition but is not the definition from the 2000 Act). All the responding States appear on the first row of the Table Mental Retardation, Cognitive or Intellectual Disability as that is the minimum definition a State may use. The subsequent rows list the States from the first row that include the specific Diagnostic Criteria indicated (e.g. cerebral palsy, epilepsy, Prader-Willi Syndrome, etc.).
Table 1: Diagnoses Reported by the States for Admission into State and Waiver Programs

Diagnostic Criteria
Mental Retardation, Cognitive or Intellectual Disability

Mental Retardation and Related Conditions

AL, CT, IA, MA, ME, MN, NE, NV, OK, PA, TN, TX, UT, VA, VT, WY NV, PA, TX, UT, WY

Developmental Disability
AK, AR, AZ, CA, CO, DC, DE, FL, GA, HI, ID, IL, IN, KS, KY, LA, MI, MO, MS, MT, NC, ND, NH, NJ, NM, NY, OH, OR, SD, WA, WV AK, AR, AZ, CA, CO, DC. FL, GA, ID, IL, IN, KS, LA, MI, MO, MT, ND, NM, NH, NJ, NY, OH, OR, SD, WA AK, AR, AZ, CA, CO, DC, FL, GA, ID, IL, IN, KS, LA, MI, MO, MT, ND, NH, NJ, NM, NY, OH, SD, WA AK, DC, DE, FL, GA, IN, KS, LA, MO, MI, MS, ND, NJ, NY, OH, OR, AK, AR, AZ, CA, CO, DC, DE, FL, GA, ID, IN, KS, MI, MO, MS, MT, ND, NH, NJ, NM, NY, OH, OR, SD, WA, WV CO, GA, IN, KS, LA, MI, MO, ND, NJ, OH, OR, SD,

Cerebral Palsy

Epilepsy

PA, TX, UT, WY

Prader-Willi Syndrome Autism

CT, NV, TX, UT WY MA, ME, PA, TX, UT, WY

Autism Spectrum

MA, NV, TX, UT, WY

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Diagnostic Criteria
Aspergers Syndrome Pervasive Developmental Disability Spina Bifida Fetal Alcohol Syndrome TBI before18 TBI before 22 At Risk before 6 Other

Mental Retardation and Related Conditions

MA, NV, TX, WY MA, NV, TX, VT, UT, WY UT, WY NV, TX, UT, WY CT, WY NV, TX, UT NV, TN, VA MA, PA, VA

Developmental Disability
DE, GA, IN, LA, MI, MO, ND, NJ, NM, OH, OR, SD AK, GA, IN, KS, LA, MI, MO, MS, ND, OH, OR, DC, FL, GA, IN, KS, LA, MI, MO, MS, ND, NJ, NM, NY, OH, OR, WV AK, GA, IN, KS, LA, ND, NY, OH, OR, SD DE, IN, MO, MS, ND, NY, OR, AK, GA, KS, LA, MO, ND, NJ, NY, OH, OR, SD, WV AZ, LA, ND, OH, OR AR, CA, CO, DC, DE, ID, IN, LA, MI, MO, MT, NC, NH, NJ, NM, NY, WA

Twenty-one (21) states reported using other diagnostic categories to determine eligibility. Additional conditions covered by states include: dyslexia (AR), autistic disorder (ME), Retts (MA), specific learning disability (NH), familial dysautonomia (NY), deaf-blind with multiple disabilities (TX), and tuberous sclerosis (WV). The majority of states do have a catch all eligibility criterion that establishes that persons are eligible who have closely related conditions with impairments in major life activities without specifying the condition.

The 10 northeastern States that we examined more closely are in bold italics. Additional examination of these States is presented in the following section. The Definitions of Ten Northeastern States For this memo we examined (in various levels of detail) the statutory, regulatory and waiver definitions, as well as the summaries contained in the Zaharia and Mosely paper of the following States: Connecticut, Delaware, Massachusetts, Maine, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont. The following five States are classified as using the Mental Retardation/Related Conditions criteria and generally include only a limited number of diagnoses (if any) in addition to mental retardation: Connecticut Maine Massachusetts Pennsylvania Vermont

Maine is unusual in this group in that Zaharia and Mosely classify the State as Mental Retardation/Related Conditions, but an examination of the Maine statute reveals that it contains the 2000 Act definition (see 5 M.R.S.A. 19503.3).

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Only New Jersey among the group of 10 States is reported to use the 2000 Act definition exclusively, and is included by the authors as one of the eight States that does so across the country. The remaining four of the ten northeastern States (including our designation of Rhode Island) use what is labeled as State DD Definition: Delaware New Hampshire New York Rhode Island

Including New Jersey but excluding Rhode Island, the authors note in Table 1 that for the remaining four States: all of them include autism, traumatic brain injury and other conditions while three of the four include (in various combinations) cerebral palsy, epilepsy and PraderWilli. In examining New Hampshires statute we found that it includes both a specific learning disability and any other condition closely related to an intellectual disability in that States definition. Included as Appendix B is the State Eligibility Criteria reported by the authors in their paper for the nine northeastern States. Based on this review and our examination of various statutes most particularly of the six New England States we conclude that the Rhode Island definition used for developmental disabilities is perhaps more liberal than the definition used by the New England States definitely so compared to Connecticut and Massachusetts, but is generally in line with the rest of the States in the nation. However, if the concern over the definition of developmental disabilities in Rhode Island is rooted in the funding commitment of the program, there may be more surgical and equitable public policy options to consider before considering a change to the current definition. These options will be briefly summarized in the final discussion of this memo. Options to Constrain Funding for Developmental Disability Services The evidence suggests that compared to most States, Rhode Island: Commits a greater fiscal effort to developmental disability services, and Has, in the last few years, reduced that commitment more significantly than all the other States Braddock in 2009 reported that Rhode Island ranked 9th among the States in fiscal effort 4 at $6.35, compared to the national average of $4.35 and the lowest State (Nevada) at $1.55. However, the $6.35 is, also according to Braddock, down from the 2006 level of $7.18 and represents a reduction of approximately 12%, which is the largest percentage reduction in the
4

Defined as spending for developmental disability services per $1,000 of aggregate statewide personal income

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nation. But continuing stress in the States fiscal situation is undoubtedly prompting policy makers to a relentless search for avenues to constrain or reduce funding requirements. We suggest there may be better alternatives to constrain or reduce funding levels than modifying Rhode Islands definition of developmental disability. We frankly believe that the current Project Sustainability is the most thoughtful and appropriate alternative. Project Sustainability is an ambitious effort to measure and track the services purchased with public dollars, establish fair and equitable rates to compensate providers for the services the State wishes to purchase (as opposed to the services the providers wish to deliver), implement a valid and reliable assessment tool to measure participants support needs, put in place new automated management tools, and have a program that provides appropriate, quality services to participants based on their need for public supports. Separate and apart from Project Sustainability and without completely understanding the freedom (or lack thereof) that the Global Waiver affords Rhode Island the Medicaid Waiver program has at least five available options to constrain or reduce funding. These five options have some serious implications particularly given the States current situation but may be more desirable than changing the definition of developmental disability. These options include: Capping the number of individuals that can participate in the HCBS program Only permit future entrants into the HCBS program that are members of targeted subgroups of the population with developmental disabilities Establish annual cost limits on the amount of resources that are devoted to support any single individual Limit the amount, duration or scope of the HCBS services offered Limit or reduce the rates paid to providers of services

A full vetting of these options is beyond the scope of this memo and are only offered as a contrast to changing the States long held commitment to providing needed services to individuals that are afflicted with serious mental or physical impairments, regardless of the cause. If this memo leaves you with any questions or you would like to discuss the material contained herein, please contact us.

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Appendix A Federal Definitions Relating to Mental Retardation and Developmental Disabilities 42 CFR 435.1010 Definitions relating to institutional status. Institution for the mentally retarded or persons with related conditions means an institution (or distinct part of an institution) that (a) Is primarily for the diagnosis, treatment, or rehabilitation of the mentally retarded or persons with related conditions; and (b) Provides, in a protected residential setting, ongoing evaluation, planning, 24-hour supervision, coordination, and integration of health or rehabilitative services to help each individual function at his greatest ability. Persons with related conditions means individuals who have a severe, chronic disability that meets all of the following conditions: (a) It is attributable to (1) Cerebral palsy or epilepsy; or (2) Any other condition, other than mental illness, found to be closely related to mental retardation because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of mentally retarded persons, and requires treatment or services similar to those required for these persons. (b) It is manifested before the person reaches age 22. (c) It is likely to continue indefinitely. (d) It results in substantial functional limitations in three or more of the following areas of major life activity: (1) Self-care. (2) Understanding and use of language. (3) Learning. (4) Mobility. (5) Self-direction. (6) Capacity for independent living.

42 CFR 441.301 Contents of request for a waiver. (b) If the agency furnishes home and community-based services, as defined in 440.180 of this subchapter, under a waiver granted under this subpart, the waiver request must (1) Provide that the services are furnished (iii) Only to recipients who the agency determines would, in the absence of these services, require the Medicaid covered level of care provided in (C) An ICF/MR (as defined in 440.150 of this chapter);

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Application for a 1915(c) Home and Community-Based Waiver [Version 3.5], Instructions, Technical Guide and Review Criteria; January 2008 Participants in a waiver linked to the ICF/MR level of care must meet the related condition definition when they are not diagnosed as having an intellectual disability (e.g., persons with autism). Mental Retardation: A condition/disability that is manifested by (1) significant sub-average intellectual functioning as measured on a standardized intelligence test; (2) significant deficits in adaptive behavior/functioning (e.g., daily living, communication and social skills); and, (3) onset during the developmental period of life (prior to age 18). While Developmental Disability and Related Conditions overlap, they are not equivalent. The definition of related conditions is at 42 CFR 435.1009, and is functional, rather than tied to a fixed list of conditions.

More discrete targeting criteria may be specified over and above the target group/subgroup and age-ranges selected in the [waiver applications] previous item. When additional criteria are not specified, it is presumed that the waiver is available to all persons who need the level(s) of care specified in the Application (Module 1) and are in the groups/subgroups selected in Item B-1-a. The additional criteria may be specified in terms of nature or degree or type of disability, or other reasonable and definable characteristics that distinguish the target group from other persons who may need the level(s) of care specified for the waiver. Such additional targeting criteria may include but are not limited to: Nature or type of disability; Specific diseases or conditions; Functional limitations (e.g., extent of assistance required in activities of daily (ADLs) and/or instrumental activities of daily living (IADLs); and, Living arrangement (e.g., persons with developmental disabilities who live with their families or in living arrangements where fewer than four persons unrelated to the proprietor reside). Additional criteria also may be specified in order to align the waiver to service population eligibility criteria that are specified in state law (for example, when a states definition of developmental disability specifies that the disability must have been experienced before age 18 rather than age 22). In specifying additional targeting criteria, clearly define the terms that are used to specify membership in the target groups. When the waiver limits the age range of the target population (e.g., to adults with physical disabilities through age 64), a state may provide that persons who enter the waiver may continue to participate in the waiver after they reach the maximum age that applies to entrance to the waiver. If the state provides for continuing individuals on a waiver past the specified maximum age, specify the continuation policies that apply.

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A waiver may target exclusively individuals who want to direct at least some or all of their waiver services by employing the participant direction opportunities that are specified in Appendix E. This targeting criterion should be reflected here.

The Developmental Disabilities Assistance and Bill of Rights Act of 2000 (P.L. 106-402 42 USC 15002(8)(A)&(B)) As provided in The Developmental Disabilities Assistance and Bill of Rights Act of 2000, the term developmental disability means a severe, chronic disability of an individual that(i) is attributable to a mental or physical impairment or combination of mental and physical impairments; (ii) is manifested before the individual attains age 22; (iii) is likely to continue indefinitely; (iv) results in substantial functional limitations in 3 or more of the following areas of major life activity: (I) Self-care. (II) Receptive and expressive language. (III) Learning. (IV) Mobility. (V) Self-direction. (VI) Capacity for independent living. (VII) Economic self-sufficiency; and (v) reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic services, individualized supports, or other forms of assistance that are of lifelong or extended duration and are individually planned and coordinated. An individual from birth to age 9, inclusive, who has a substantial developmental delay or specific congenital or acquired condition, may be considered to have a developmental disability without meeting 3 or more of the criteria if the individual, without services and supports, has a high probability of meeting those criteria later in life. [N.B., The foregoing definition is not the same as the Medicaid specification of individuals who may receive ICF/MR services. ICF/MR services are furnished to persons with mental retardation and other related conditions. When a waiver targets individuals with developmental disabilities, a state should define its use of the term developmental disability.]

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Appendix B Selected State Eligibility Criteria From: State Strategies for Determining Eligibility and Level of Care for ICF/MR and Waiver Program Participants (2008)

Connecticut Mental Retardation/Related Conditions Definition: Must have significantly sub average general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period or a medical diagnosis of Prader-Willi. Citation: Conn. General Statute Sec. 17a-210 Delaware State DD Definition: Must have mental retardation, autism, Aspergers, Prader-Willi, or Brain Injury during the developmental period with concurrent adaptive limitations. Citation: Delaware Register of Regulations (3-1-08), Maine Mental Retardation/Related Conditions: Must have diagnosis of mental retardation or autism/autistic disorder; must show impairments in one domain of Activities of Daily Living; must meet criterion on BMS-99 Citation: http://www.maine.gov/sos/cec/rules/10/144/ch101/c2s021.doc Massachusetts Mental Retardation/Related Conditions: Adults over age 18 must have mental retardation or, for children, 8 or under, must have autistic disorder, Retts, childhood disintegrative disorder, PDD, or Aspergers, with severe behavioral, communicative, or social deficits that interfere with the ability to remain in the home or the community; must meet criterion on the MASSCAP. Citation: http://www.mass.gov/dmr Regulations, Ch.6 New Hampshire State DD Definition:

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A disability which is attributable to mental retardation, cerebral palsy, epilepsy, autism, a specific learning disability or any other condition closely related to mental retardation, resulting in impairment in general intellectual functioning or adaptive behavior, which originated before age 22 and constitutes a severe disability to function normally in society; Citation: NH He-M 524 New Jersey Federal DD Definition: A severe, chronic disability attributable to mental or physical impairments, manifesting before age 22 and resulting in substantial functional limitations in 3 or more areas of major life activity; for those over age 12, must meet criterion on the Self Care Assessment Tool. New York State DD Definition: A disability that is attributable to mental retardation, cerebral palsy, epilepsy, autism, neurological impairment or any other condition closely related to mental retardation, resulting in impairment of general intellectual functioning or adaptive behavior and manifesting before age 22, and constitutes a substantial handicap to the persons ability to function normally in society; dyslexia may be included if resultant of one of the other related conditions. Citation: MHL 1.03 (22); OMRDD Eligibility Determination Policy Advisory Pennsylvania Mental Retardation/Related Conditions: Mental retardation Citation: 55Pa.Code Chapter 6210: Bulletin 00-08-04 Vermont Mental Retardation/Related Conditions: Mental retardation or related conditions; must meet criterion on Needs Assessment/Periodic Review Citation: AHS DAIL, Regs. implementing DD Act of 1996

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Appendix C New England States - Comparison of Developmental Disability Eligibility Criterion

State Connecticut Statute/AdministrativeRule Mentalretardationmeanssignificantlysubaveragegeneralintellectual functioningexistingconcurrentlywithdeficitsinadaptivebehaviorand manifestedduringthedevelopmentalperiod. (b)Asusedinsubsection(a)ofthissection,generalintellectualfunctioning meanstheresultsobtainedbyassessmentwithoneormoreoftheindividually administeredgeneralintelligencetestsdevelopedforthatpurposeand standardizedonasignificantlyadequatepopulationandadministeredbya personorpersonsformallytrainedintestadministration;significantlysub averagemeansanintelligencequotientmorethantwostandarddeviations belowthemeanforthetest;adaptivebehaviormeanstheeffectivenessor degreewithwhichanindividualmeetsthestandardsofpersonal independenceandsocialresponsibilityexpectedfortheindividual'sageand culturalgroup;anddevelopmentalperiodmeanstheperiodoftime betweenbirthandtheeighteenthbirthday. C.G.S.A.11g.a

Massachusetts "Personwithanintellectualdisability'',apersonwho,asaresultof inadequatelydevelopedorimpairedintelligence,asdeterminedbyclinical authoritiesasdescribedintheregulationsofthedepartment,issubstantially limitedintheperson'sabilitytolearnoradapt,asjudgedbyestablished standardsavailablefortheevaluationofaperson'sabilitytofunctioninthe community;provided,however,thatapersonwithanintellectualdisability maybeconsideredmentallyill;providedfurther,thatnopersonwithan intellectualdisabilityshallbeconsideredmentallyillsolelybyvirtueofthe person'sintellectualdisability. M.G.L.123B.1

Rules: 115CMR66.04:GeneralEligibility (1)Personswhoare18yearsofageorolderareeligibleforsupportsprovided, purchased,orarrangedbytheDepartmentiftheperson: (a)isdomiciledintheCommonwealth;and (b)isapersonwithintellectualdisabilityasdefinedin115CMR2.01.

115CMR2.0:Definitions: IntellectualDisabilityisthepreferredtermtodescribetheconditionof mentalretardation,and,forpurposesof115CMR2.00,issynonymouswith thetermmentalretardation. MentalRetardationmeanssignificantlysubaverageintellectualfunctioning existingconcurrentlyandrelatedtosignificantlimitationsinadaptive functioning.Mentalretardationmanifestsbeforeage18.Apersonwithmental retardationmaybeconsideredtobementallyillasdefinedin104CMR

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State

Statute/AdministrativeRule (DepartmentofMentalHealth),providedthatnopersonwithmental retardationshallbeconsideredtobementallyillsolelybyreasonofhisorher mentalretardation

Maine "Mentalretardation"meansaconditionofsignificantlysubaverage intellectualfunctioningresultinginorassociatedwithconcurrentimpairments inadaptivebehaviorandmanifestedduringthedevelopmentalperiod. Developmentaldisabilitymeansaseverechronicdisabilitywhichis attributabletoamentalorphysicalimpairmentorcombinationof impairments;ismanifestedbeforethepersonattainsagetwentytwo(22);is likelytocontinueindefinitely;resultsinsubstantialfunctionallimitationsin three(3)ormoreofthefollowingareasofmajorlifeactivity:selfcare, receptiveandexpressivelanguage,learning,mobility,selfdirection,capacity forindependentliving,economicselfsufficiency.Apersonfrombirththrough 9yearsofagewhohasasubstantialdevelopmentaldelayorspecificcongenital oracquiredconditionmaybeconsideredtohaveadevelopmentaldisability withoutmeeting3ofthecriteriastatedinthissubsectionifthereisahigh probabilitythatthepersonwillmeetthosecriterialaterinlifeifservicesand supportsarenotprovidedtotheperson;andreflectstheperson'sneedfora combinationandsequenceofspecial,interdisciplinaryorgenericcare, treatment,orotherserviceswhichareoflifelongorextendeddurationand areindividuallyplannedandcoordinated. 5M.R.S.A.19503.3

PervasiveDevelopmentalDisordersTheOfficeusesthedefinitionofautism codifiedin34BMRSA6002.Autismreferstoadevelopmentaldisorder characterizedbyalackofresponsivenesstootherpeople,grossimpairmentin communicativeskillsandunusualresponsestovariousaspectsofthe environment,allusuallydevelopingwithinthefirst30monthsofage (MaineDepartmentofHealthandHumanServices,OfficeofAdultswith CognitiveandPhysicalDisabilities,DefinitionofMentalRetardationand Autism;AppealPolicy)

NewHampshire Developmentaldisabilitymeansadisability: (a)Whichisattributabletoanintellectualdisability,cerebralpalsy,epilepsy, autism,oraspecificlearningdisability,oranyotherconditionofanindividual foundtobecloselyrelatedtoanintellectualdisabilityasitreferstogeneral intellectualfunctioningorimpairmentinadaptivebehaviororrequires treatmentsimilartothatrequiredforpersonswithanintellectualdisability; and(b)Whichoriginatesbeforesuchindividualattainsage22,hascontinued orcanbeexpectedtocontinueindefinitely,andconstitutesaseveredisability tosuchindividual'sabilitytofunctionnormallyinsociety. N.H.R.S.171A2.V.

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State RhodeIsland

Statute/AdministrativeRule DevelopmentallyDisabledAdultmeansaperson,eighteenyearsoldorolder andnotunderthejurisdictionoftheDepartmentforChildren,Youthand FamilieswhoiseitheranMRdevelopmentallydisabledadultorisaperson withaseverechronicdisabilitywhich: isattributabletoamentalorphysicalimpairmentorcombinationof mentalandphysicalimpairments; ismanifestedbeforethepersonattainsage22; islikelytocontinueindefinitely; resultsinsubstantialfunctionallimitationsinthreeormoreofthe followingareasofmajorlifeactivity: o selfcare, o receptiveandexpressivelanguage, o learning o mobility, o selfdirection, o capacityforindependentliving, o economicselfsufficiency reflectsthepersonsneedforacombinationandsequenceofspecial, interdisciplinaryorgenericcare,treatment,orotherservices,which areindividuallyplannedandcoordinated.(RIGen.Laws40.1214.3 (5))

MRdevelopmentallydisabledadultmeansaperson18yearsorolderand notunderthejurisdictionoftheDepartmentofChildren,YouthandFamilies, withsignificantsubaverage,generalintellectualfunctioningtwostandard deviationsbelowthenorm,existingconcurrentlywithdeficitsinadaptive behaviorandmanifestedduringthedevelopmentalperiod.(RIGen.Laws40. 1214.3(8))

Vermont Developmentaldisabilitymeansasevere,chronicdisabilityofapersonthat ismanifestedbeforethepersonreachestheageof18andresultsin:(A) mentalretardation,autismorpervasivedevelopmentaldisorder;and(B) deficitsinadaptivebehavioratleasttwostandarddeviationsbelowthemean foranormativecomparisongroup. 18V.S.A.8722 Rules(DivisionofAgingandDisabilityServices)March2011CodeofVermont Rules13110011 1.13DevelopmentalDisabilitymeansanintellectualdisabilityoraPervasive DevelopmentalDisorderwhichoccurredbeforeage18andwhichhas significantdeficitsinadaptivebehaviorthatweremanifestbeforeage18. Temporarydeficitsincognitivefunctioningoradaptivebehaviorastheresult ofsevereemotionaldisturbancebeforeage18arenotadevelopmental disability.Theonsetafterage18ofimpairedintellectualoradaptive functioningduetodrugs,accident,disease,emotionaldisturbance,orother causesisnotadevelopmentaldisability.

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State

Statute/AdministrativeRule

1.18Intellectualdisabilitymeanssignificantlysubaveragecognitive functioningthatisatleasttwostandarddeviationsbelowthemeanfora similaragenormativecomparisongroup.Thisisdocumentedbyafullscale scoreof70orbelowonanappropriatenormreferencedstandardizedtestof intelligenceandresultinginsignificantdeficitsinadaptivebehaviorthatwere manifestbeforeage18.Intellectualdisabilitywaspreviouslyknownas mentalretardationasthetermisdefinedandreferredtointhe DevelopmentalDisabilitiesAct.

1.20PervasiveDevelopmentalDisorder(PDD)meansthesameastheterm asitisdefinedinthecurrentDiagnosticandStatisticalManualofMental Disorders(DSM).Thediagnosticcategoryofpervasivedevelopmental disordersincludesthefivediagnosescurrentlylistedinDSM:AutisticDisorder (Autism),Asperger'sDisorder,PervasiveDevelopmentalDisorder,Not OtherwiseSpecified,Rett'sDisorderandChildhoodDisintegrativeDisorder.

1.38Wasmanifestbeforeage18"orweremanifestbeforeage18means thattheimpairmentandresultingsignificantdeficitsinadaptivebehaviorwere observedbeforeageeighteen.Evidencethattheimpairmentandresulting significantdeficitsinadaptivebehavioroccurredbeforetheage18maybe baseduponrecords,informationprovidedbytheindividual,and/or informationprovidedbypeoplewhoknewtheindividualinthepast.

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