What is TEFRA?
What are the Level-of-Care (LOC) categories?
What is a medical cost determination?
Why do I need a care coordinator?
How will I know if my child is approved for TEFRA?

1. What is TEFRA?

Tax Equity Fiscal Responsibility Act (TEFRA) is a Medicaid program specifically designed for children with disabilities and significant medical needs. TEFRA only provides Regular Medicaid coverage. No special services are provided under this category of Medicaid. Children eligible for coverage under other categories of Medicaid (DKC, Family Medicaid, etc.) should continue to receive coverage under those categories. In order to qualify for TEFRA Medicaid, a child must meet ALL of the following:

a. Must be less than 19 years of age, and

b. Must be living in the home of the biological or adoptive parent, 

    and

c. Must meet the definition of Social Security Disability (SSI), and

d. Must meet one of three (3) possible Level-of-Care categories,

    and

e. The child’s income and resources must be within the Specialized Medicaid Income limits.

2. What are the Level-of-Care (LOC) categories?

TEFRA Medicaid has three (3) LOC categories:

• Intermediate Care Facility for the Mentally Retarded (ICF/MR)
• Nursing Facility (NF)
• Inpatient Psychiatric Hospital (IPH)

Each of these LOC categories has specific State-regulated criteria for determining eligibility. Qualis Health reviews application documentation to determine if these criteria are met. Not all children who are determined disabled meet a LOC category. Also, high medical costs do not mean a child will meet a LOC or disability definition.

3. What is a medical cost determination?

“I received a letter saying I need to contact the Qualis Health TEFRA nurse for a medical cost determination.”

A medical cost determination (a.k.a. Cost of Care) is a form that is submitted as part of your child’s application for review by a Qualis Health nurse reviewer. The care coordinator you choose to work with has access to this form and will help you complete and submit it on your behalf to Qualis Health.

4. Why do I need a care coordinator?

TEFRA has a very complex application process; therefore, your care coordinator is a valuable resource for you in the TEFRA process. They act as the main point of contact between you and the various agencies involved in the application process and have access to the application forms that need to be submitted. Qualis Health will work directly with your care coordinator to ensure timely submittal of all application documentation. Care coordinators bill the State of Alaska for the services they provide.

5. How will I know if my child is approved for TEFRA?

Along with the age, location and parental income requirements for TEFRA stated in question #1; three of the qualifications (d, e and f) require approval notifications from these agencies:

• The DPA verifies the financial eligibility and resources of your child. Once approved an annual review is required.
• The DDS determines if your child meets the SSI disability criteria and will send notifications to the DPA. Once approved an annual review may be required.
• Qualis Health reviews application documentation to determine if the LOC criteria are met and sends notifications to the DPA. Once approved an annual review is required.

When the DPA receives all three of these approvals they will send you an official notification letter