One of the requirements to qualify for TEFRA is that your child must meet one of three level-of-care (LOC) criteria. The three LOC categories for TEFRA are:
-
Intermediate Care Facility for the Mentally Retarded (ICF/MR)
-
Nursing Facility (skilled and/or intermediate) (NF)
-
Inpatient Psychiatric Hospital (IPH)
Each of these LOC categories has specific application criteria that must be met for your child to qualify for TEFRA. Your care coordinator will determine which one of the above LOC applications to submit during their initial interview with you.
As a parent applying for TEFRA Medicaid, your main job is to make sure that the application process moves forward by supplying the required documents and working with your care coordinator to keep track of the progress of your child’s application. Here is some general information that will help you understand the application process.
There are many agencies and/or people that must work together to process a TEFRA Medicaid application:
-
-
-
-
-
-
Parent(s) – you are ultimately responsible to make sure that the documentation for your child’s application is being processed in a timely manner.
Click here for TEFRA process flow chart.
1. DPA is the central agency in all TEFRA Medicaid eligibility decisions. When checking for financial eligibility for TEFRA Medicaid, the DPA caseworker does not count the parental income or resources.
The DPA caseworker will verify your child’s income and resources to make sure they do not exceed the following:
- Income $1656 or less per month
- Liquid resources $2000 or less
The DPA case worker will also:
- Make a referral to the DDS for a disability determination after you return the required forms
- Make a referral to Qualis Health for a medical determination
As a parent you will be responsible to make sure the initial and annual financial eligibility forms get submitted to the DPA in compliance with their specified time lines.
2. DDS completes “State-only” disability decisions for the DPA using the same Federal Social Security Regulation that is used for Supplemental Security Income (SSI). To be eligible for TEFRA Medicaid, your child must be determined disabled by the DDS. The forms to complete a DDS decision must be returned to the DPA caseworker.
3. DSDS complete an ICAP assessment (an objective scoring tool used by an assessor during an interview) based on a referral from Qualis Health to determine child meets ICF/MR criteria.
4. Qualis Health is a contractor employed by the State to review TEFRA applications for State-defined medical criteria. When Qualis Health receives a referral from the DPA we:
- Open a pending TEFRA application for your child
- Send you an introduction/welcome letter requesting you select a care coordinator from a list we provide and notify us within 30 days of your selection
- Work with your care coordinator to ensure that the proper documentation is submitted in compliance with the State-regulated timelines
- Track the progress of all new and renewal applications
Once Qualis Health receives all application documentation from your care coordinator we:
- Review your child’s application to see if he/she meets the State medical criteria for this program
- Notify your care coordinator and the DPA of the decision
5. Care Coordinating Agency / Care Coordinator will work directly with the DPA, Qualis Health and you to assist you in providing all the required documentation in a timely manner.
Once you sign a Release of Information the care coordinator can help you:
- Gather appropriate medical documentation for the disability determination
- Complete the proper documentation to submit to Qualis Health for the medical LOC determination
As a parent, you will be responsible to maintain contact and work cooperatively with your care coordinator. Your care coordinator is a valuable resource for you in the TEFRA process. They act as the main point of contact for the agencies listed above and have access to the various application forms that need to be submitted.
