03 Eligibility Status
Revised: 08/03
03-02 Eligibility
03-02-01 Requirements
The applicant must have a physical or mental impairment; which constitutes or results in a substantial impediment to employment; and
Vocational Rehabilitation services are required to prepare for, secure, retain or regain employment consistent with the applicant's unique strengths, resources, priorities, concerns, abilities, capabilities, interests, and informed choice; and
The applicant can benefit in terms of an employment outcome from vocational rehabilitation services.
An applicant who has a physical or mental impairment which constitutes a substantial impediment to employment is presumed to be able to benefit from vocational rehabilitation services unless the counselor can demonstrate, based on clear and convincing evidence, that the applicant is incapable of benefiting in terms of an employment outcome from vocational rehabilitation services due to the severity of the applicant's disability. This must be demonstrated by providing trial work experiences or through an extended evaluation period, as appropriate, while in applicant status, in order to explore the participant's abilities, capabilities and capacity to perform in work situations in order to demonstrate whether the individual can achieve an employment outcome.
Clear and convincing evidence means a high degree of certainty that an individual is incapable of benefiting from services in terms of an employment outcome. Clear and convincing means unequivocal; free from obscurity or ambiguity. Generally, existing information will not provide clear and convincing evidence that an employment outcome is not achievable. Clear and convincing evidence might include:
a description of assessments, including situational assessments and supported employment assessments, from service providers who have concluded that they would be unable to meet the individual's vocational needs due to the severity of the individual's disability. In addition, the involvement of the participant in "in-house" assessments - testing, homework assignments, participation in relevant group activities - may assist in making such a determination.
if appropriate, a functional assessment of skill development activities with any necessary supports (including assistive technology) in real life settings.
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03-02-02 SS Presumption of Eligibility
An applicant is eligible for VR services if he or she is eligible for Social Security benefits under Title II (SSI) or Title XVI (SSDI) and the case should be moved into eligible status, unless the counselor can demonstrate by clear and convincing evidence that the individual is incapable of benefiting from vocational rehabilitation services in terms of an employment outcome due to the severity of the disability. Clear and convincing evidence must be demonstrated by providing trial work experiences or through an extended evaluation period, as appropriate, while in applicant status, in order to explore the participant's abilities, capabilities and capacity to perform in work situations in order to demonstrate whether the individual can achieve an employment outcome.
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03-02-02-01 Guidelines for SS Presumption of Eligibility
The applicant eligible for VR services based on the SSDI/SSI Presumption of Eligibility is automatically determined to be an individual with a significant disability. They may also be considered to be a person with most significant disability, but this will require additional justification on the eligibility datapage.
The applicant's completion of the application process following explanation from DVR staff that individuals who receive services under the program must intend to achieve an employment outcome sufficiently demonstrates their desire to achieve an employment outcome.
When an applicant reports receipt of SSDI or SSI benefits, all efforts should be made to have the participant and/or guardian provide an award letter or copy of check to verify receipt of benefits. If the participant is unable to produce verification of benefits, a release form should be signed and submitted to SSA or other appropriate sources.
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03-02-03 Guidelines for Eligibility Determination
The VR counselor is responsible for making eligibility decisions. Counselor judgment is a critical factor in all issues of eligibility, particularly in determining the types of diagnostics necessary to determine eligibility and the best resources available for those diagnostics. Timelines, quality and informed participant choice must all be considered relative to the acquisition of essential diagnostic service.
Persons needing surgery or specific short-term medical or dental treatment are generally not eligible if the surgery is expected to correct the condition with little or no residual effects. The existence of a medical problem, regardless of the immediate or current effect, does not necessarily constitute an impediment to employment.
Persons with chronic impairments that are currently in remission (multiple sclerosis, cancer) are considered to be disabled if the impairment has created functional limitations, or, if without treatment the impairment may become active again. The other eligibility criteria must still be met.
Eligibility determinations are applied without regard to sex, race, age, creed, color, national origin, and type of disability, economic status or availability of comparable services and benefits.
An individual must be physically available for services and living in New Mexico. There is no residential time or legal proof requirement such as driver's license, voting registration, etc.
An individual cannot be served by more than one state rehabilitation agency at the same time. American Indians may be eligible for services under the DVR program and the American Indian Vocational Rehabilitation Program (Section 121) simultaneously. Also, eligible veterans may receive vocational rehabilitation services from the Veterans Administration VR program and DVR simultaneously. IPE development must be coordinated with the American Indian or Veterans Administration VR programs to assure appropriate use of comparable benefits and non-duplication of services.
Legalized aliens may be eligible for VR services based on meeting other agency requirements. DVR is unable to provide services to individuals who are not US citizens or do not have an Alien Registration Receipt Card, Form I-151 or I-1551 (commonly referred to as "Green Cards") or an Employment Authorization Document (commonly referred to as a "work permit") issued from the Immigration and Naturalization Services.
Eligibility determinations must be made in a reasonable period of time, not to exceed 60 days after the individual has submitted an application. There are only three occasions in which is it appropriate that an eligibility decision not be made within the 60-day time limit. Those situations include agreement by counselor and participant to extend the time limit through an Eligibility Determination Extension, to enter Trial Work Experiences or to enter an Extended Evaluation period.
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03-02-03-01 Procedures for Eligibility Determination
Review information related to eligibility and make a determination whether the applicant meets DVR eligibility criteria.
Determine the level of disability if the individual is determined eligible. There are three levels of disability:
Not Significantly Disabled - An individual who has a physical or mental condition who does not meet the criteria for either of the levels described below.
Significantly Disabled- An individual:
who has one or more physical or mental disabilities resulting from amputation, arthritis, autism, blindness, burn injury, cancer, cerebral palsy, cystic fibrosis, deafness, head injury, heart disease, hemiplegia, hemophilia, respiratory or pulmonary dysfunction, mental retardation, mental illness, multiple sclerosis, muscular dystrophy, musculo-skeletal disorder, neurological disorders (including stroke and epilepsy), spinal cord conditions (including paraplegia and quadriplegia), sickle cell anemia, specific learning disability, end-state renal disease, or another disability or combination of disabilities determined on the basis of an assessment for determining eligibility and vocational rehabilitation needs; for which,
is seriously limited in one or more functional capacities (such as mobility, communication, self care, self direction, interpersonal skills, work tolerance, or work skills) in terms of an employment outcome; and
for whom vocational rehabilitation can be expected to require multiple vocational rehabilitation services over an extended period of time.
Most Significantly Disabled- An individual who has a severe physical or mental impairment that:
Impedes the individuals functional capacities in two or more areas (such as mobility, communication, self care, self direction, interpersonal skills, cognitive abilities, or work tolerance or attendant factors) in terms of an employment outcome, and
for whom competitive employment has not traditionally occurred or has been interrupted or intermittent; and
whose vocational rehabilitation can be expected to require multiple and intensive vocational rehabilitation services in order to result in an employment outcome.
Discuss the decision with the participant. It is important that the participant understand that a positive eligibility determination does not imply any services requested or discussed to date are automatically approved but that identification of specific services will be determined during the development of the Individualized Plan for Employment.
Complete the Eligibility Determination datapage in AWARE, sign and file a hardcopy in the case file. Since the portions of the Disability datapage is part of documenting the eligibility determination, it is important that the counselor update the Disability datapage to accurately reflect correct diagnosis and other relevant information identified during the eligibility assessment. Reported disabilities, which the counselor was unable to substantiate through diagnostic reports, should be removed from the Disability datapage with explanation in a contact note. Both the Disability datapage and Eligibility Determination can be updated at any time to reflect new information. Any updated Eligibility Determinations should be printed, signed by the counselor and placed in the case file.
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03-02-04 Requirements for Ineligibility
An individual is ineligible for VR services if the individual does not meet one or more of the eligibility criteria. (Any of the following reasons may constitute the basis for a determination of ineligibility):
No physical or mental impairment exists and is substantiated by medical, psychological or other case data.
A physical or mental impairment exists; however, the impairment does not result in a substantial impediment to employment based on counselor analysis of information obtained during the assessment.
The counselor has demonstrated by clear and convincing evidence that the applicant is incapable of benefiting from VR services in terms of an employment outcome due to the severity of their disability and this is demonstrated through participation in trial work experiences or extended evaluation period. When an applicant has been determined incapable of benefiting from VR services, a referral must be made to a local extended employment provider.
VR services are not required for the individual to enter, return to or maintain employment.
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03-02-04-01 Procedures for Determining Ineligibility
Provide an opportunity for full consultation with the applicant or, as appropriate, the representative prior to determination of ineligibility. The participant may be excluded from consultation if he/she refuses to consult, is unavailable or whereabouts are unknown. The case record must contain documentation of reasonable effort made to afford him/her an opportunity for consultation prior to case closure.
Complete the Closure datapage choosing the appropriate reason for closure and providing rationale for the decision in the narrative section.
Inform the participant or, as appropriate, the participant's representative in writing, supplemented as necessary by other appropriate modes of communication consistent with the informed choice of the individual, of the ineligibility determination. Include the reasons for the determination and information regarding participant rights and responsibilities.
Refer the applicant to any other agencies or facilities as appropriate, including Independent Living Centers, extended employment providers, etc.
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03-02-04-01-01 Annual Review of Ineligibility Decision
When ineligibility is based on the participant's inability to benefit in terms of an employment outcome, the counselor must review the determination within 12 months of the date that ineligibility was declared.
The purpose of the annual review is to review new information or changes in circumstances that may affect the determination that the participant "cannot benefit in terms of an employment outcome". Reviews are made on an individual basis with the participant or as appropriate, the participant's representative.
Continuation of annual reviews of ineligibility determinations after the initial annual review will occur only at the request of the participant or as appropriate, the participant's representative. This may occur anytime after the initial review and conditions applicable to the initial review will apply to additional reviews.
Annual review is not required in cases where:
the participant has refused services/review;
the individual is unavailable;
the individual's whereabouts are unknown;
the participant's medical condition is rapidly progressive or terminal; or
the ineligibility decision is based on non-existence of a disabling condition, no substantial impediment to employment or VR services are not required.
AWARE provides a listing of reviews due in Caseload Reports under federal follow-up needed. The follow-up browse shall be completed to document Annual Review of Cases Closed Ineligible. See AWAREHelp.
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03-02-05 Guidelines for Closure Because the Participant is Unavailable
A distinction must be made between ineligibility and unavailability. A person is only ineligible if they fail to meet one or more of the eligibility criteria; they are not necessarily ineligible if they are unavailable. An applicant's case cannot be closed prior to making an eligibility determination unless the applicant is unavailable. An applicant is unavailable if he/she has:
died
moved out of state
not responded to reasonable efforts to contact
been institutionalized under circumstances rendering the individual unavailable for preliminary or thorough diagnostic studies or VR services for an indefinite or considerable period of time; or
declines to participate in appropriate VR services designed to assess eligibility despite reasonable efforts made to the participant or as appropriate, the participant's representative, to encourage the participant's participation.
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03-02-06 Procedures for Closure
Complete Closure datapage - identifying reason for closure and providing a rationale in the comment section.
Document attempts to contact the participant or, as appropriate, the participant's representative in the case file.
Notify participant in writing of case closure, where appropriate, and provide information regarding participant's rights to appeal the decision.
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