DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20922 (08/2008)
STATE OF WISCONSIN
DETERMINATION OF NO ACTIVE TREATMENT (NAT) RATING
Name Applicant/Participant Date of Birth County of Residence
To be eligible for CIP II/COP-W, persons with developmental disabilities must receive a No Active Treatment (NAT) rating. The NAT rating must be determined at application and then re-determined annually by a person who is a Qualified Mental Retardation Professional (QMRP). To qualify for an initial NAT rating or for continuation of the NAT rating, either items 1, 2 (and at least one sub-item), or 3 must be checked.
He/she has a developmental disability such as epilepsy, brain injury prior to age 22, autism, or cerebral palsy with NO mental retardation AND he/she is able to function with little supervision. [CFR 483.440(a)(ii)(2)].
2. He/she is 65 years of age or older, has a developmental disability AND also mental retardation, BUT whose needs are similar to elderly residents of a nursing home. The individual has reached his/her maximum potential as evidenced by checking at least one of the following items:
Degenerative health status requiring skilled nursing intervention.
B. All treatment programs have been discontinued due to the determination that the maximum benefit has been reached. C. Adaptive behavioral assessments by community service boards and other professionals indicate that he/she has reached his/her maximum potential and the major portion of care is maintenance of present skills and no further growth is expected. 3. He/she has a developmental disability, is 65 years of age or older, and has a life expectancy of less than 12 months. 4. The individual is NOT eligible for a NAT rating because: A. He/she is under the age of 65 and has mental retardation B. Other:
SIGNATURE QMRP Making Determination SIGNATURE BLTS Staff Completing Review (initial application only) Date Signed Date of Review
Date SIGNATURE of QMRP