Section 4.6. Assessment

(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.

Notation

Cross References

This section cited in 25 Pa. Code § 4.7 (relating to enrollment).