533 A.     TEFRA ELIGIBILITY

Eligibility is subject to all of the following conditions:

1. The child must be under 19 years of age. When a child is turning 18 years old, they must be referred to apply for SSISupplemental Security Income.

2. The child must meet the disability criteria for SSISupplemental Security Income eligibility, meaning that disability has been determined by the Disability Determination Service (DDS).

3. The child would be eligible for Medicaid if institutionalized, under the Special LTCLong Term Care Income Standard listed in Addendum 1 and using the $2,000 APA-related resource limit. This eligibility category generally follows provisions in the APAAdult Public Assistance manual.

Exceptions:

• Only the income and resources of the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 child are countable. Child support received on behalf of the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 child is countable income to the child.

• Coverdell funds are not a countable resource for the account beneficiary (usually the disabled child).

• 529 plans (also known as a Qualified Tuition Program) are a countable resource for the account owner (usually the parent), but are not a countable resource for the account beneficiary (usually the disabled child).

• UTMA/UGMA accounts are not countable income or resources to the minor. However, if funds from these accounts are used to support the minor, they are counted as income in the month of receipt and as a resource the following month.

4. The child resides at home, not in a residential care setting. Temporary absence from the home is allowable. Children are not eligible for TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 while living in an institution.

Note:

While home is not restricted to living with the child's parents, in almost all cases a child not living with parents will be eligible for Medicaid under a less restrictive category of Medicaid, such as MAGI Medicaid. These children should not be evaluated for TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 unless a change in circumstances is anticipated in the near future.

5. The child meets one of the following level of care (LOC) standards:

• Acute care hospital, nursing facility, or intermediate care facility (NF-LOC);

• Intermediate care facility for the Intellectually Developmentally Disabled (ICF-IDD-LOC); and

• Inpatient psychiatric hospital (IPH-LOC).

The department contracts with Comagine Health to determine or facilitate the determination of the appropriate level of care. 

6. The child is deemed appropriate to receive necessary medical care outside of that institution, as indicated on a Support Plan approved by Comagine Health.

7. The estimated cost of care (COC) for services rendered in the home must be less than the cost of institutionalization, as determined by Comagine Health. This process is referred to as cost neutrality.

The DPADivision of Public Assistance caseworker is responsible for ensuring that the applicant meets criteria 1 through 4 above and all other Medicaid program requirements.

Comagine Health is responsible for ensuring that an applicant meets criteria 5 through 7 above, which are referred to as the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 medical/cost criteria.

The caseworker must make sure that Comagine Health has approved the applicant and the DDS has determined disability before the child is authorized for Medicaid under this eligibility category.

Children in this category are eligible for all regular Medicaid services but they do not receive Home and Community Based (HCB) waiver services.