07109 Program Planning and Monitoring Under Provisional Eligibility

Link to TCADD policy 7101

SCOPE:

This procedure applies to all intake and service coordination staff of Tri-Counties Regional Center (TCRC). An Individual Program Plan (IPP) shall be developed for any child, found eligible for regional center services as defined in Welfare & Institutions Code (W&I) 4512 (a)(2) to include provisional eligibility.  Provisional eligibility applies to children who are under five years of age who are not eligible under the definition of a developmental disability but meet the criteria for provisional. A child shall be provisionally eligible if the disability is not solely physical in nature and has significant functional limitations in at least two areas of major life activity: self-care, receptive and expressive language, learning, mobility, or self-direction.  

PURPOSE:

The purpose of provisional eligibility is to provide supports to children under five years of age, who do not meet eligibility criteria for Lanterman services because they do not have a qualifying developmental disability and/or three or more areas of significant functional limitations in the identified areas.   

The service coordinator role remains the same, to provide person and family centered planning and coordination of services in partnership with the child’s family with consideration to child’s age, natural, community, generic, and regional center services and supports.

This includes the collection and dissemination of information to clinicians and management for the purpose of decision making with developmental monitoring, eligibility decisions, and services and support.

Children who are provisionally eligible may qualify for institutional deeming and Medicaid-Waiver, if they have two Waiver eligible deficits documented on their CDER as well as are using a qualified purchase of service at least once per year. Waiver eligible deficits should consider what is age-appropriate and what is due to the substantial delay, or developmental disability.

Children under Provisional eligibility are not eligible to access the Self Determination Program (SDP).

PROCEDURE:

1. Program Planning and Monitoring:
2. Review the child’s SANDIS Welcome Screen that she/he is under Status U.
3. Review the Statement of Provisional Eligibility (SOPE) to be familiar with:
4. Child’s disability
5. Areas of functional limitation
6. Any monitoring considerations provided by the clinical team.
7. The re-assessment date (at least 90 days prior to the child’s fifth birthdate).
8. Additional items to review for familiarity with the child if available:
9. Psychological evaluation.
10. If coming from Early Start, review all records (e.g. 30-34 months developmental report, medical records).
11. If coming from intake, review all records (e.g. interview, educational records, medical notes).
12. Reach out to the family for the IPP planning meeting:
    1. If child is under the age of three (3), outcomes and planning agreements may be documented in the IFSP and an initial IPP completed by age three (3).
13. For MediCal Waiver consideration:
14. Review child’s eligible developmental delays and diagnosis.
15. Review possible MediCal Waiver qualifiers as it pertains to #1.
16. Has a qualifying purchase of service to support need.
17. Remember MediCal Waiver ends as of fifth birthdate under provisional status.
18. Follow referral submission guidance from TCRC Benefits Coordinator.

1. The Individual Program Plan (IPP):
2. When developing IPPs for children, regional centers shall be guided by the principles, process and services and support parameters set forth in W&I Code Sections 4646 & 4685. Refer to the IPP Guidelines for IPP planning guidance and requirements and TCRC Procedure #9102 for Developing the Individual Program Plan.
3. S-IPP Signature Page under Additional Notes: State this is a provisional IPP and Provisional Eligibility will end by the fifth birthdate.

 Parental Consent: Include on the consent any references needed for record gathering (e.g. school, CCS, ABA provider, pediatric office, any specialist).

• Frequency of IPP Meetings:
• A child newly eligible to regional center under provisional must have an IPP developed within sixty (60) days of the eligibility determination date.
• IPPs must be completed at least on a triannual basis and not go beyond the month for the fifth birthday, ending on or the day before.
• For all active cases, individual program plans shall be reviewed and modified by the planning team as necessary in response to any request and/or changing needs. If the parent, legal guardian or authorized representative requests an IPP review, the IPP shall be reviewed within 30 days of the request.
• Age Four Annual Review of the IPP:
• Schedule the IPP Annual Review meeting and send the Notice of Provisional Eligibility Annual Review Letter
• Have a planning meeting to review the IPP.
• Check on IPP goals, progress, changes in development; determine if new information on the consent is needed (e.g. new school, additional specialist).
• Remind parent/ legal guardian of the provisional eligibility end date and the need to do further assessment.
• If on MediCal Waiver, or initiating waiver, remind parent the waiver ends when provisional ends by the fifth birthdate (unless found eligible for Lanterman due to developmental disability). Discuss the parents’ plan for health insurance as of age five.
• Enter the Annual Review in T-19 Notes in SANDIS.
• At age 4.6 complete a subsequent review or as near to as possible.
• If there are any changes in development, you may consult with the clinical team for possible considerations or guidance.
• Provisionally Eligible after Age Four:
• Have a planning meeting for initial IPP. Refer to above I, II (A, B, C).
• Remind parent/ legal guardian of the provisional eligibility end date and the need to do further assessment.
• Enter the IPP T-19 Note in SANDIS.
• The IPP is to end one day before the fifth birthdate, or on the fifth birthdate.
• At age 4.6 complete a subsequent review or as near to as possible.
• If changes in development consult with clinical for possible considerations or guidance.

1. Case Monitoring and Records:
2. All requests for evaluation for Status 2 made prior to age 4.6 should be reviewed by the planning team and include the local clinical team or manager for consultation.
3. Eligibility Determination:
4. For a child to be eligible for continued Lanterman services at age five (Status 2) she or he must meet the definition of a developmental disability as defined in W&I Code section 4512 (a)(1), and this decision is made by the interdisciplinary team within the regional center.
5. Timelines:
6. Age four, if needed, send the case information to TCRC clinicians for review only.
7. Age 4.5 determine if additional information is needed (additional records, evaluation recommendations, etc.)
8. Age 4.6 prepare the referral to a staff/vendor psychologist as determined in subsequent review.
9. Ages 4.9 determine eligibility and send the notice to parent/ legal guardian letting them know the outcome.
10. Final eligibility determination is made through Core Staffing with local clinical/eligibility team. This is to include the TCRC staff psychologist, a physician, the manager, and service coordinator.
11. Child is eligible:
12. The service coordinator informs the family of their child’s diagnosis and eligibility status within five days of staffing. The child is now eligible for self-determination.
13. Enter a T-19 Eligibility Note in SANDIS.
14. Prepare the Statement of Eligibility (SOE) and process electronically for signatures to manager, psychologist, and physician.
15. Prepare the Letter of Eligibility and process for signatures.
16. Provide letter to support staff to send via the family’s preferred method of communication: email (HIPPA compliant), mail or fax.
17. Confirm CDER has the report date, height, weight, date weighed and current CDER is in the SANDIS chart prior to any changes.
18. Send signed SOE to Federal Programs Department support staff.
19. Update the IPP for definitive eligibility at age five. IPP term is three years.
20. Child is not eligible:
21. The service coordinator informs the family of the results of their child’s evaluation and eligibility status.
22. If on MediCal Waiver, have parent sign the disenrollment form and send it to the TCRC Federal Programs Assistant Director and the Benefits Coordinator.
23. Offer the family a feedback session with a staff psychologist to review assessment results and answer any questions they may have.
24. Prepare the Eligibility Denial and process electronically for signatures to manager, psychologist, and physician.
25. Prepare the Notice of Action (NOA) and Letter for Denial/Notice of Decision and process for signatures. Provide to support staff to send to the family via their preferred method of communication: email (HIPPA compliant), mail or fax, within three days from the date received, along with the Appeals Packet.

*NOAs must be drafted by a SC or Manager.

• If Med Waiver disenrollment form is not signed, include a statement of termination on the NOA.
• Enter a T-19 Closing Note in SANDIS.
• Update manager and support staff with request to close.
• Support staff to close the case within 3 business days in SANDIS once manager has provided the T19 approval.

• Transfers:
• Children transferred to TCRC from another regional center must have an IPP developed within thirty (30) days of the acceptance of transfer. If transferring a child from TCRC to another regional center reference the process for Inter-Regional Center Transmittal.

• Close/Re-Open as Status U:
• When closing a child’s case under status U follow regular closing procedures. To re-open a case under status U verify the child has not yet reached his or her fifth birthdate. If prior to the fifth birthdate re-open under status U and follow timelines of eligibility. Provisional eligibility still ends on the fifth birthdate.

Revision Date: August 2025