Chapter 7: Determining Eligibility

7.1 Overview

Only the counselor may make an eligibility determination. The counselor does so by carefully reviewing information provided by the consumer, the consumer’s family or representative, physicians who have examined or treated the consumer, and data from other professional agencies who have knowledge of the consumer. CRS program staff members also use existing information from previous episodes of care.

If additional assessments are necessary to determine whether a consumer is eligible, the assessment must be conducted in the most integrated setting possible and be consistent with the consumer's needs and informed choice.

Do not use CRS funds to pay for assessments that require inpatient hospitalization.

7.2 Basic Eligibility Criteria

To meet the basic eligibility criteria for the CRS program, there must a reasonable expectation that services will benefit the person by improving his or her ability to function within the home or community, and the person must:

  • have a traumatic brain injury (TBI) or traumatic spinal cord injury (TSCI) that constitutes or results in a substantial impediment to the person's ability to function within the home environment or the community;
  • be at least 15 years of age;
  • be a U.S. citizen or lawful permanent resident, and a Texas resident as evidenced by a Texas driver's license, an identification card with an address issued by a governmental entity, a utility bill with an address, a voter registration card, a vehicle registration receipt, or other document approved by CRS; as defined in 1.2 Key Terms; 
  • not be participating in, or be eligible for and able to access, another rehabilitation program offering similar rehabilitation treatment or therapy services; however the person may participate in rehabilitation programs that offer complementary rehabilitation services;
  • be willing to participate in services; and
  • be medically stable, including no progression of deficits, no deterioration of physical and cognitive status, or both; not be in imminent need of any acute care; and be functioning at a Level IV of the Rancho Los Amigos Levels of Cognitive Functioning Scale or equivalent.

The person's continued eligibility for the CRS program will be reviewed and, if he or she no longer meets all criteria explained in this section, program services may be discontinued.

NOTE: Equivalent to Rancho Level IV

When medical service providers do not clearly indicate the Rancho level, you may:

  • review the medical records with medical professionals and determine the level of functioning;
  • use the documented Glasgow Coma Scale score (a score of 9-15 is equivalent to a Level IV on the Rancho Los Amigos Levels of Cognitive Functioning Scale; or
  • document the level of functioning in a case note.

If the Rancho Los Amigos level or Glasgow Coma Scale score cannot be found, consult with the consumer’s treating medical professional to get the necessary information.

If you must use alternative documentation, clearly document what was used, how you made your determination, and what medical professional supports your determination.

7.3 Insufficient Documentation to Determine Eligibility

When documentation from the consumer's treatment providers is not conclusive, and you cannot determine eligibility, begin assessments necessary to help determine eligibility.

When there is insufficient documentation to determine eligibility, assessments must include:

  • an appraisal of the consumer's general medical condition;
  • documentation of a traumatic brain injury (TBI) and/or traumatic spinal cord injury;
  • a determination of whether the consumer is medically stable enough to actively participate in planned services; and
  • a recent appraisal of psychological and other factors that relate to the consumer's ability to participate in planned services, such as a psychological evaluation or neuropsychological evaluation, and a neuropsychological evaluation for individuals with TBIs.

You may spend funds for assessments without removing the consumer from the Interest and Waiting Lists.

7.4 CRS Eligibility Statement

The rationale for the eligibility decision must be evident in ReHabWorks (RHW). If the consumer meets CRS eligibility criteria, complete DARS5107, Comprehensive Rehabilitation Services Eligibility Statement in RHW. This document becomes available in RHW upon confirming eligibility in the system. The eligibility decision must clearly indicate what you used to determine eligibility and must confirm that the individual meets each eligibility criterion. (DARS5107 is available only in RHW)

7.5 Nondiscrimination

Determine eligibility for services without regard to gender, age, race, religion, color, national origin, type of expected rehabilitation outcome, type of disability, source of referral, particular services needed, or anticipated cost of services required by a consumer.