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Effective: December 1, 2006 |
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03.30.25ar1 - TEFRA Option (Archive) |
Archived: July 1, 2008 |
The TEFRA option provides MA eligibility to some disabled children who live with their families. It is commonly known as ”r;TEFRA” because it was part of the Tax Equity and Fiscal Responsibility Act of 1982. This option provides for the waiver of parental deeming requirements for children who meet all of the following:
l Are under age 19.
Note: Although federal guidelines allow TEFRA eligibility up to age 19, since parental income is not deemed to disabled 18-year-olds, they will generally not need the TEFRA option.
l Live with at least one parent.
l Are MA-eligible except for parental income.
l Need a certain level of home health care to stay at home.
n The level of home care would compare to that provided in a hospital, nursing home or an intermediate care facility for persons with mental retardation and related conditions (ICF/MR).
n The cost for home care would not be more than MA would pay for the child's care in a medical institution.
There are no additional services provided under the TEFRA option. Its sole benefit is providing MA eligibility for otherwise-ineligible children through the waiver of parental deeming requirements.
Eligibility factors are listed below with any information that is unique for this group. Links to standard program guidelines are included as well.
Citizenship/Immigration Status.
Insurance and Benefit Recovery.
Relationship to Other Groups/Bases.
Other Groups/Bases to Consider.
Application Process (standard guidelines)
Follow the disabled guidelines.
Follow standard MA guidelines.
Renewals (standard guidelines)
Do not require the parents of TEFRA enrollees to re-verify their income at renewal unless the parents report an income decrease that would make the child eligible for MA without a spenddown under another basis with parental income deemed.
Example:
Emily, age six, is disabled and requires TEFRA-level home and community-based services. Her parents’ income exceeds MA limits.
Action:
Approve Emily for MA under the TEFRA option, which allows a waiver of parental income.
On the annual renewal form, Emily’s parents report decreased income. It appears Emily may now qualify for MA without a spenddown under a disabled basis of eligibility.
Action:
Request income verification. If Emily no longer requires a TEFRA certification to qualify for MA, do not require a SMRT determination for continued TEFRA eligibility. Approve ongoing MA under a disabled basis.
Verifications (standard guidelines)
TEFRA enrollees must have a disability determination from the State Medical Review Team (SMRT).
Follow MA guidelines for Children Under 21.
The TEFRA option is available to undocumented or non-immigrant children who are ineligible for Emergency Medical Assistance (EMA) because of their parents' income.
Note: These children are eligible only for EMA-covered services.
Follow standard MA guidelines.
Insurance and Benefit Recovery (standard guidelines)
Policies that cover TEFRA enrollees are considered cost-effective by the Benefit Recovery Section (BRS) and do not require further review if the child's portion of the premium is $50 or less per month.
Use a household size of one. See income guidelines below for information about deeming.
Use the regular MA household size and income to determine eligibility for the Medicare Savings Programs for TEFRA enrollees.
Use Method B for income.
There is no asset limit for children under 21, regardless of their basis of eligibility.
Income Guidelines (standard guidelines)
The income limit is 100% FPG.
Count only the child's income; do not deem parental income.
Note: Parents may be liable for a fee to reimburse part of the child’s MA costs. See parental fees for more information.
Exclude child support and RSDI payments received by or on behalf of children under age 18.
Use the following Method B deductions in the order given:
1. Income used to fulfill an approved Plan to Achieve Self Support (PASS) for disabled or blind people.
2. Earned income disregard for blind or disabled student children.
3. The first $65 of earned income disregard.
4. Work expense deduction for disabled clients.
5. One-half the remaining earned income.
6. Work expense deduction for blind clients.
Spenddowns (standard guidelines)
Children with incomes over 100% of FPG may be eligible by spending down to 75% FPG.
Follow MA guidelines for Children Under 21.
People under age 65 who are eligible for MA due to blindness or disability are excluded from managed care enrollment.
Note: People under age 65 who are certified as disabled but who choose a non-disabled basis of eligibility may voluntarily enroll.
A child who is eligible for MA without a spenddown under another basis does not need a TEFRA certification. This includes:
l Children who are eligible for MA through Transitional/Transition Year MA (TMA/TYMA).
l Children who are eligible as auto newborns.
l Children who are eligible for MA without a spenddown under any other basis when parental income is deemed.
l Children who receive Supplemental Security Income (SSI).
Example:
Chad is three years old, and lives with his parents. He is disabled and needs a level of home care that meets TEFRA requirements. However, with his parents' income deemed to him, he is eligible for MA without a spenddown as a disabled child.
Action:
Approve MA for Chad under a disabled basis of eligibility; do not request a TEFRA certification.
A child who receives services through the CADI, CAC, TBI or DD waiver programs does not need a TEFRA certification.
Refer TEFRA enrollees who turn age 18 to SSI if they continue to have disabilities.
l Leave MA open as a disabled child ages 18-21 while the SSI determination is pending.
l If SSI determines that the child is not disabled and the child continues to live with the parents, deem parental income.
If children lose MA eligibility under another basis, but appear to meet all of the conditions for TEFRA, request a TEFRA certification. Leave MA open while the SMRT determination is in process.
l If SMRT approves TEFRA, continue eligibility as a TEFRA case.
l If SMRT determines the child is ineligible for TEFRA and there is no eligibility when parental income is deemed, close MA for the first month for which you can give 10-day notice.
Note: If the family appeals the SMRT decision, follow continuing benefits.
Example:
Mona is a disabled child who lives with her mother and brother. They are MA-eligible as a parent/caretaker and a child under 21. Mona’s mother begins employment.
l The family is no longer eligible for MA without a spenddown, but they qualify for Transition Year Medical Assistance (TYMA).
l When TYMA ends, Mona’s mother and brother no longer qualify for MA without a spenddown.
l Mona continues to require a level of home care comparable to what would be provided in a hospital, nursing home, or ICF/MR.
Action:
Request a TEFRA certification from SMRT. Close TYMA and open Mona as a disabled child pending the SMRT decision.
Not applicable.