MEDICAID - TEFRA
Oklahoma Health Care Authority (OHCA)
PURPOSE
TEFRA (Tax Equity and Fiscal Responsibility Act of 1982) is a Medicaid program that allows children with disabilities to be cared for in their homes. In TEFRA, only the child’s income, not the family’s, is counted to decide if he or she is eligible. TEFRA is for children who meet an institutional level of care for a hospital, nursing facility, or intermediate care facility for the mentally retarded. (The child does not have to be institutionalized to meet the level of care.) Children with disabilities eligible under TEFRA will get full health insurance coverage under Medicaid services that include coverage with Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). See Page 37.
CONTACT
Debbie Harmon
TEFRA Services
Oklahoma Health Care Authority
4545 N Lincoln Blvd, Ste 124
Oklahoma City, OK 73105
(405) 522-7300
Email: debbie.harmon@okhca.org
http://www.okhca.org/client/programs/tefra/tefra.asp
See Appendix B for Department of Human Services County Offices.
FINANCIAL CRITERIA
• None
ELIGIBILITY
To be eligible, a child must meet the following requirements:
Meet the Social Security definition of disability;
Be under the age of 19;
Have qualifying income and resources;
Meet an institutional level of care. The three levels are: intermediate care for the mentally retarded, nursing facility, or hospital;
It 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
Fabrication of Devices
Training for Consumer & Family
Maintenance & Repairs
Case Management
Information & Referral
Locating Alternate Funding
Advocacy/Other
AT DEVICES PROVIDED/COVERED
Hospital Beds
Wheelchairs & Mobility Aids
Aids for Hearing Impaired
Medical Supplies
Aids for Vision Impaired
Prosthetics & Orthotics
Augmentative Communication
Seating & Positioning Equipment
Environmental Controls
APPLICATION PROCESS
Apply for TEFRA at the local DHS office (the same process as applying for Medicaid).
Call the county office to see if you need to schedule an appointment
Bring 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 the tele-service representative about your child’s eligibility for SSI.
A completed TEFRA-1 Physician Assessment Form. The form is available from the Oklahoma Department of Human Services County Offices, the SoonerCare Helpline or the Oklahoma Health Care Authority websites.
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 will not have third party insurance coverage, indicate the full cost of each service provided.
APPEALS 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 LD-1 form within 20 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 20 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 CEO, which is a record review at which the parties do not appear.
5. Member appeals are to be decided within 90 days from the date OHCA receives the member’s timely request for a fair hearing unless the member waives this requirement.
PIECES OF THE PUZZLE
A home visit will be made during the application process to see if safe and appropriate care can be provided in the home.
The criteria for institutional level of care is complex; children under the age of 6 will be required to undergo a full psychological evaluation, including both intelligence testing and adaptive/functional assessment by a licensed psychologist, at age 3 and again at age 6 to ascertain continued eligibility for TEFRA under the ICR/MR level of institutional care. The psychological evaluation must be completed and submitted to Level of Care Evaluation Unit no later than 90 days following the child’s 3rd and 6th birthday.
Once determined eligible the child is covered for up to 12 months. You must reapply every year.
If your child has private insurance coverage that you intend to maintain in addition to any TEFRA you must:
use your insurance first,
follow the rules of your insurance,
see providers who have contracts with both your insurance and Medicaid SoonerCare in order to be fully covered for all costs of services.
