ELIGIBILITY

HOW TO APPLY:

Process and Forms Needed to Apply for Long Term Medicaid

In an effort to provide the highest level of care, it is important that Inner Peace Respite Services receive all of the following forms and information. Please download, fill out, and email to us!

For Children and Adults Ages 5+

The State of Colorado requires four things to determine eligibility:

Proof of a cognitive, adaptive, or intellectual disability
Proof that the disability occurred prior to age 22
Why the applicant is disabled (medical diagnosis)
A signed application for disability determination

STEP ONE:

Fill out the request for a Developmental Disability Determination, Release of Health Information and the acknowledgment page of Inner Peace's HIPAA Policy

ENGLISH Disability Determination

SPANISH Disability Determination

HIPPA Acknowledgement

Realease of Health Information

STEP TWO:

Review the accepted testing options below and arrange a test or submit results from a previous test

Cognitive Testing (preferred)

The score shall be determined using a norm-referenced, standardized test of general intellectual functioning and administered by a licensed psychologist or school psychologist. The following are the Assessments tools recommended by the State of Colorado:

Differential Ability Scale (DAS)
Kaufman Assessment Battery for Children (KABC)
Leiter International Performance Scale (Leiter)
Stanford Binet (SB)
Wechsler Adult Intelligence Scale (WAIS)
Wechsler Intelligent Scale for Children (WISC)
Wechsler Preschool and Primary Scale of Intelligence (WPPSI)

Adaptive Behavior Assessment

In order to ascertain if an applicant meets the State criteria an adaptive assessment may be needed to reflect the applicant’s true abilities. Adaptive Behavior will be considered if the overall adaptive behavior composite or equivalent score is two or more standard deviations below the mean and would also require a documented neurological diagnosis as well. Measurements shall be a norm-referenced, standardized assessment of adaptive behaviors that are appropriate to the person’s living environment. The following Assessment tools are recommended by the State of Colorado:

Adaptive Behavior Assessment System (ABAS)
Adaptive Behavior Scale-Revised (ABS-R)
Scales of Independent Behavior-Revised (SIB-R)
Vineland Adaptive Behavior Scale (VABS)

When determining the overall adaptive behavior score, a maximum confidence level of 90% shall be applied to the overall adaptive behavior score to determine if the interval includes a score of 70 or less. The adaptive scale shall be determined using interview and record review and not through questionnaires. All domains must be considered in determining the overall adaptive behavior score. An adaptive assessment MUST be accompanied with third party documentation of a neurological diagnosis (such as Down syndrome, cerebral palsy, Autism spectrum disorder or seizure disorder).

STEP THREE:

Download, Print, Fill out, and Email Forms

Email Documents To:

office@innerpeacerespite.com

Call for Questions:

970-640-8576