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Effective: December 1, 2006 |
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12.15ar1 - TEFRA Referrals to the State Medical Review Team (SMRT) (Archive) |
Archived: September 1, 2010 |
The TEFRA option provides MA eligibility for some disabled children who live with their parents. One requirement for all TEFRA children is a State Medical Review Team (SMRT) disability and level of care determination. Only SMRT has the authority to evaluate disabilities for TEFRA certification.
TEFRA Documentation Requirements.
Length of TEFRA Certification.
TEFRA Documentation Requirements
Like other referrals to SMRT, all TEFRA option referrals must include a completed Determination of Disability form (DHS-1467A), as well as documentation to support the child's physical, psychological or mental retardation/developmental delay (MR/DD) condition. However, TEFRA referrals also require physical and/or psychological evidence specific to the child's condition.
The Request for Children's Medical Examination (DHS-0161B) is recommended for use as a request for, as well as release of, medical information. All TEFRA referrals must include the information noted on the "SMRT - TEFRA Option" documentation form specific to the child's condition:
l Required Documentation - Physical Disability (DHS-3854).
l Required Documentation - Developmental Disability (DHS-3855).
l Required Documentation - Mental Health Disability (DHS-3856).
Note: For current TEFRA cases, SMRT will send these documentation requirements forms to county agencies 90 days prior to the end of a TEFRA enrollee's disability determination end date for recertification.
As outlined on the forms noted above, some of the requirements include:
l Results of a routine physical examination (no more than three months old) signed by a medical doctor.
l A Children's Activities of Daily Living form (DHS-2904A) completed by the child's parents.
l If applicable, an Individual Education Plan (IEP) that is current within one year, along with the most recent Team Assessment Summary.
Further details about each of the above requirements, as well as a number of additional requirements specific to each condition, are given on the forms.
Assist applicants and enrollees in gathering medical information and completing forms as needed. If funds are needed to pay for testing required by SMRT to determine disability, submit a claim for access services with procedure code 99456 (disability exam).
Current TEFRA enrollees must cooperate in submitting all medical documentation for renewal of MA eligibility and for TEFRA recertification. If an enrollee who would not qualify for MA without TEFRA certification:
l Fails to cooperate in submitting medical information by the due date, send a timely closing notice for failure to cooperate with the TEFRA certification process.
l Is cooperating but is unable to supply all medical documentation by the due date, leave the case open until the information is received and SMRT has made a decision.
For information on how to submit the referral to SMRT, see SMRT Disability Determinations.
After receiving SMRT's decision:
l Send notification of the decision to the child's parents. This notification may include a copy of the notice sent by SMRT to the county agency.
l Parents of TEFRA-eligible children may be responsible to pay parental fees as partial reimbursement of the child's MA costs. After approving eligibility for the child under the TEFRA option, send a completed County Parental Fee Referral form (DHS-2982) to DHS.
SMRT may approve a TEFRA certification for up to a maximum of four years. SMRT's decision on the frequency of review of disability and level of care is a decision that may not be appealed.
For further information, see:
SMRT Disability Determinations.