Medicaid – TEFRA Care of Children with Disabilities

Medicaid – TEFRA Care of Children with Disabilities

Purpose

TEFRA (Tax Equity and Fiscal Responsibility Act of 1982) gives states the option to make Medicaid (SoonerCare) benefits available to children with severe physical or mental disabilities, who would not ordinarily be eligible for Supplemental Security Income (SSI) benefits because of their parent’s income or resources. This option allows children who are eligible for institutional services to be cared for in their homes. Children with disabilities eligible under TEFRA will get full health insurance coverage under Medicaid services that include coverage with SoonerCare Child Health Program.

Contact

TEFRA Services
Oklahoma Health Care Authority
4345 N Lincoln Blvd
Oklahoma City, OK 73105
405-522-7752 (OHCA)
Email: TEFRAfax@okhca.org
http://www.okhca.org/

Eligibility

  • Be under the age of 19;
  • Meet the Social Security definition of disability;
  • Not qualify for other SoonerCare programs;
  • Meet one of the three levels of institutional care which are: intermediate care facility for the intellectually disabled, nursing facility, or hospital;
  • Must be appropriate to care for the child at home;
  • The estimated cost of caring for the child at home cannot exceed the estimated cost of caring for the child in the institution.

AT Services Provided/Covered

  • Assessments & Evaluations
  • Maintenance & Repairs
  • Case Management
  • Information & Referral

AT Devices Provided/ Covered

  • Aids for Hearing Impaired
  • Mobility/Seating & Positioning
  • Speech Communication
  • Environmental Adaptations
  • Aids for Vision Impaired

How to Get the AT

  • Apply for TEFRA by sending an email to TEFRAfax @okhca.org or calling 405-522-7752.
  • The TEFRA worker will send an application packet with forms and instructions. The worker will schedule a phone interview.
  • Obtain a denial letter from the Social Security Administration (SSA). If you do not have a denial letter, call SSA at (800) 772-1213 and talk to a representative about your child’s eligibility for SSI.
  • Complete a TEFRA-1 Physician Assessment Form. This form will be in the packet sent to you from the TEFRA worker.
  • If your child has private insurance coverage that you intend to maintain in addition to any TEFRA eligibility, please document only your actual costs per month for the services listed. If the service is not covered by the insurance provider, or you do not have third-party insurance coverage, indicate the full cost of each service provided.
  • Prior Authorization for all types of durable medical equipment (DME) is required by the Oklahoma Health Care Authority. It is the responsibility of the chosen DME provider to submit requests for review. DME providers will need to obtain supporting objective documentation (including items like an evaluation report and a Certificate of Medical Necessity (CMN) (as applicable)) from a qualified therapist (Ex. Occupational Therapist, Physical Therapist, or Speech-Language Pathologist) required for prior authorization request submissions. Prior authorization guidelines can be found at: https://oklahoma.gov/ohca/providers/medical-authorization-unit.html on the following types of DME:
      • Audiology Services
      • Communication (Alternative Augmentative Communication) Devices
      • Durable Medical Equipment
      • Incontinence Supplies
      • Wound Care Supplies
      • Vision

Pieces of the Puzzle

  • Once financial eligibility for TEFRA has been established, the TEFRA application and documents will be reviewed to evaluate whether the criteria for disability, institutional level of care, cost-effectiveness, and safety and appropriateness have been met. To avoid unnecessary delays in processing the application, please make sure that both you and the child’s physician have completed all sections of the TEFRA-1 assessment form. In addition, OHCA will need supplemental documentation to support information provided on the TERFA-1 document.
  • Once determined eligible the child is covered for up to 12 months. The worker will send a request for updated documents approximately 10 months after the certification month.
  • If the child has private insurance coverage that the family intends to maintain in addition to any TEFRA you must:
    • use your insurance first;
    • follow the rules of your insurance; and
    • see providers who have contracts with both your insurance and Medicaid SoonerCare in order to be fully covered for all costs of services.
  • All DME purchased with Oklahoma Medicaid funds become the property of the OHCA to be used by the recipient until no longer needed. When the SoonerCare member no longer needs the valuable DME they may contact the Oklahoma Durable Medical Equipment Reuse Program (OKDMERP) so it can be refurbished, repaired if needed, and reassigned to another Oklahoman at no cost. Priority is given to SoonerCare members for the first 60 days. Call OKDMERP staff at 833-431-9706 or go to okabletech.org for more details.

Dispute Resolution Process

  1. The appeals process allows a member to appeal a decision involving medical services, prior authorizations for medical services, or discrimination complaints.
  2. In order to file an appeal, the member files a Member Complaint/Grievance Form (LD)-1 form within 30 days of the triggering event.  The triggering event occurs at the time when the member knew or should have known of such condition or circumstance for appeal.  The staff advises the Appellant that if there is a need for assistance in reading or completing the grievance form that arrangements will be made.
  3. If the LD-1 form is not received within 30 days of the triggering event or if the form is not completely filled out with all necessary documentation, OHCA sends the Appellant a letter stating the appeal will not be heard.
  4. Upon receipt of the member’s appeal, a Fair Hearing before the Administrative Law Judge (ALJ) will be scheduled.  The member will be notified in writing of the date and time for this procedure.  The member must appear at this hearing.  The ALJ’s decision may be appealed to the Chief Executive Officer (CEO), which is a record review at which the parties do not appear.
  5. Member appeals are ordinarily decided within 90 days from the date OHCA receives the member’s timely request for a Fair Hearing unless the member waives this requirement.