533           DISABLED CHILDREN AT HOME (TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248)

A disabled child who does not qualify for SSISupplemental Security Income cash assistance due to parental income or resources may be eligible for Medicaid based on the child's own income and resources.  Children in this category are often called TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 kids (named after the Tax Equity and Fiscal Responsibility Act, P.L. 97-248 that authorized this eligibility category).  The LTCLong Term Care Unit processes this specialized eligibility category.

533 A.        TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 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 (DDSDisability Determination Service).
    

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 APAAdult Public Assistance-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 a 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 MAGIModified Adjusted Gross Income Medicaid.  These children should not be evaluated for TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 unless a change in circumstance is anticipated in the near future.

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

• Acute care hospital, nursing facility, or intermediate care facility (NFAcute Care Hospital, Nursing Facility, or Intermediate Care Facility-LOCLevel of Care);  

• Intermediate care facility for the Intellectually Developmentally Disabled (ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled-LOCLevel of Care); and  

• Inpatient psychiatric hospital (IPHInpatient Psychiatric Hospital-LOCLevel of Care).

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 (COCCost-of-care) 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 DDSDisability Determination Service 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 (HCBHome and Community-Based) waiver services.

533 B.      TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 CONVERSIONS

When a child is eligible for another category of Medicaid, such as SSISupplemental Security Income or MAGIModified Adjusted Gross Income, and has been determined to meet one of the three LOCLevel of Care categories, the case is referred to as a deferred TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 case.  It is important that parents are given a choice of the category of Medicaid they wish their child to receive.  Take the following steps for a potential deferred TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 case and current cases:

1. SSISupplemental Security Income Children

1. When SSISupplemental Security Income starts, the case must be converted to an SSISupplemental Security Income Medicaid case with the DC-54 MEREMedical Reference coding.
    

2. Comagine Health must be notified that the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 case has been changed to an SSISupplemental Security Income Medicaid case and advised to close the Comagine Health case. Comagine Health can be emailed at AKTefra-Waiver@Qualishealth.org.
    

3. Document the LOCLevel of Care renewal date and set an alert that this was a former TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 child.
    

4. The SSISupplemental Security Income case is then transferred to the appropriate local office.

If the child's SSISupplemental Security Income benefit stops, the caseworker must evaluate the child's eligibility for MAGIModified Adjusted Gross Income Medicaid, TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248, and a Continuous Eligibility Period (CEP).  

• If there is no MAGIModified Adjusted Gross Income Medicaid, TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248, or a CEPcontinuous eligibility period, the case must be closed and a new application is required.

• If there is eligibility for MAGIModified Adjusted Gross Income Medicaid but not TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248, open the MAGI Medicaid case and let the parents know that they can pursue TEFRA if they wish.

• If there is no eligibility for MAGI or TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 but the child has a CEPcontinuous eligibility period, the Medicaid case will continue until the CEP ends. The case should be referred to the LTCLong Term Care unit to determine TEFRA eligibility. In order for TEFRA case to be opened, the case must meet the LOCLevel of Care and disability diary date requirements. The LTCLong Term Care unit will work with the parents and Comagine Health. LTC unit will check the LOC and email Comagine Health at AKTefra-Waiver@Qualishealth.org to reopen the LOC case if there is a current LOC in place. If there is no LOC, the TEFRA case will be pended for LOC to be determined. The LTC unit will check the disability diary date. If there is no disability diary date, the case must be pended for a disability determination.

2. TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 and MAGIModified Adjusted Gross Income

With every TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248Tax Equity and Fiscal Responsibility Act, P.L. 97-248 application, the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 Tax Equity and Fiscal Responsibility Act, P.L. 97-248 caseworker must screen for potential MAGIModified Adjusted Gross Income Medicaid eligibility.  If there appears to be MAGIModified Adjusted Gross Income eligibility, the family should be notified of this and be allowed to pursue this coverage.  The family should be advised that there may be a lapse in coverage after MAGI ends while pursuing TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 eligibility. Parents should be offered the opportunity to pursue TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 Tax Equity and Fiscal Responsibility Act, P.L. 97-248 and maintain TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 Tax Equity and Fiscal Responsibility Act, P.L. 97-248 eligibility as a backup.  If the parent chooses to pursue TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248:

1. Register a new case with the child as PI;
    

2. Pursue a disability determination;
    

3. Refer the child for a LOCLevel of Care determination by Comagine Health; and
    

4. Transfer the MAGIModified Adjusted Gross Income case to the LTCLong Term Care Unit.

If LOCLevel of Care and disability are approved, the parent must be contacted and given the choice of having the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 case opened or maintaining the child's Medicaid eligibility within MAGIModified Adjusted Gross Income.  If the parent opts to continue eligibility with MAGIModified Adjusted Gross Income, the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 caseworker will close the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 case and document eligibility via MAGIModified Adjusted Gross Income.  

If MAGIModified Adjusted Gross Income closes for earned income or failure to renew, the MAGIModified Adjusted Gross Income caseworker should notify the LTCLong Term Care Unit to review TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 eligibility and take the following actions:

• Review case for LOCLevel of Care status and DDSDisability Determination Service status.
   

• If both LOCLevel of Care and disability status are current, open the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 case and notify Comagine Health that the case is now open and to reactivate the case in the Comagine system.
   

• If LOCLevel of Care or disability status has lapsed, pend the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 case for current disability approval and LOCLevel of Care.

The EISEligibility Information System case notes and alert system must clearly indicate which child is the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 eligible child in the home.

3. Institutionalized Children

Children may go between their home and inpatient treatment.  This happens most often with the IPHInpatient Psychiatric Hospital-LOCLevel of Care.  

TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 Recipients

If a TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 child enters an inpatient facility the caseworker must contact the family to determine the anticipated length of stay.  If the stay will be for more than six months, Comagine Health must be notified to close the LOCLevel of Care case.

If the stay is expected to last more than 30 days, convert the case to a child only MAGIModified Adjusted Gross Income case and transfer the case to the appropriate local office.

When the child is ready to return home, the MAGIModified Adjusted Gross Income caseworker must notify the LTCLong Term Care Unit.  The LTCLong Term Care Unit must review LOCLevel of Care Level of Care and disability status for TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 Tax Equity and Fiscal Responsibility Act, P.L. 97-248 eligibility.  If disability and LOCLevel of CareLevel of Care are not current, the LTCLong Term Care Unit must initiate the process for both.    

New Applications and Institutionalized Children  

A TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 application may be received at the same time that the family is pursuing inpatient care for their child.  If the child is institutionalized prior to TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 eligibility being established and the stay is anticipated to be greater than 30 days, take the following actions:

1. Open a child only MAGIModified Adjusted Gross Income case and transfer the case to the appropriate local office;
    

2. Set an alert and case note alerting the MAGIModified Adjusted Gross Income worker that this is a potential TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 child; and
    

3. Notify the family to contact their care coordinator, the LTCLong Term Care Unit, and Comagine Health when a discharge date is determined so the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 process can be initiated prior to the child's return.

Note:

A new application is not needed to go between one category of Medicaid and another.  Caseworkers must use the alert and case note system to identify these children and make appropriate referrals to maintain coverage and ensure there are no breaks in service.

533 C.      REFERRAL AND INTERAGENCY COMMUNICATIONS

Communication is essential to ensure a quick and timely determination.  The agencies and individuals involved in a TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 Medicaid eligibility decision and their roles are outlined below.

1. Comagine Health is responsible for:
 

• Referring families to care coordination agencies and the LTCLong Term Care Unit;
    

• Working closely with care coordinators regarding the medical eligibility decision and required paperwork;
   

• Making NFAcute Care Hospital, Nursing Facility, or Intermediate Care Facility-LOCLevel of Care and IPHInpatient Psychiatric Hospital-LOCLevel of Care review determinations, including notifying care coordinators and families of the annual LOCLevel of Care renewal requirement;

• Making the Support Plan and COCCost-of-care review determinations for the NFAcute Care Hospital, Nursing Facility, or Intermediate Care Facility-LOCLevel of Care and IPHInpatient Psychiatric Hospital-LOCLevel of Care cases;

• Making the Support Plan and COCCost-of-care review determinations for ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled-LOCLevel of Care cases and maintaining a record of the LOCLevel of Care approval by DSDSDivision of Senior and Disabilities Services; and

• Emailing the DPADivision of Public Assistance LTCLong Term Care Unit, the DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst and Care Coordinators when LOCLevel of Care is approved or emailing the DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst when LOCLevel of Care is denied.

2. The Care Coordination Agency is responsible for:

• Completing and submitting the Support Plan, COCCost-of-care, and LOCLevel of Care documentation to Comagine Health for all NFAcute Care Hospital, Nursing Facility, or Intermediate Care Facility-LOCLevel of Care and IPHInpatient Psychiatric Hospital-LOCLevel of Care cases;

• Completing the Support Plan and COCCost-of-care for ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled-LOCLevel of Care cases and working with DSDSDivision of Senior and Disabilities Services in the development and completion of the Inventory for Client and Agency Planning (ICAP) assessment packet;
  

• Submitting all necessary information to Comagine Health and DSDSDivision of Senior and Disabilities Services ;
   

• Explaining to parents that they must complete a DPADivision of Public Assistance application with a referral to the appropriate DPADivision of Public Assistance office; and
   

• Contacting parents when the annual LOCLevel of Care reassessment is due.

Note:   

TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 care coordinators only receive payment for screening, initial assessment, and yearly reassessment for LOCLevel of Care and the Support Plan.  TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 does not pay for monthly care coordination.

3. The Disability Determination Service (DDS) is responsible for:

• Starting the disability determination process upon receiving the disability packet from the DPADivision of Public Assistance caseworker; and
   

• Determining if a child is disabled using Social Security Administration criteria.

It is beneficial to include copies of relevant medical, psychological, and developmental information in the DDSDisability Determination Service packet in order to speed up the disability process.  This may include Infant Learning assessments, Individual Education Plans, current medical records (from within the past year), counseling reports, etc.  See APAAdult Public Assistance Manual Section 425-3(C) and Administrative Procedures Manual Section 115-9 for policy and procedures on disability determinations.

Note:

If the DDSDisability Determination Service Disability Determination Servic decision       ded              decision is a denial of disability, the DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst will issue a closure letter to the parent(s).

4.  DPADivision of Public Assistance  is responsible for:

• Sending the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 welcome letter (MED 16) and TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 Medicaid for Disabled Children at Home brochure (MED 15) to the parent or guardian whenever an application is received for TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 Medicaid.  This must be documented in a CANOCase Notes.

Note:

The MED 16 is not the same welcome letter that Comagine Health sends the child’s parent, as described in section 533-D(2).

• Completing the Medicaid eligibility determination;
   

• Submitting the disability packet to DDSDisability Determination Service for initial applications, tracking disability review dates, and submitting a disability review at the applicable time;
   

• Making referrals to Comagine Health with the GEN 140B form once the family has interviewed;
   

• Pending the application until all factors of eligibility are met.  TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 applications must be approved or denied within 90 days.  Follow the procedures below:

• Pend new applications for 60 days from the date of application.

• Send the M320, Information Needed - TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 notice, to pend a TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 application.  Send a copy of this notice to the Care Coordinator.

• On day 61:

1. If the LOCLevel of Care decision is missing, notify Comagine Health and request a LOCLevel of Care update.  If LOCLevel of Care has not been determined and it appears the decision may go past 90 days, contact the DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst.  The DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst will work with Comagine Health to determine the appropriate action.  The LTCLong Term Care Unit will be notified of status.

2. If the DDSDisability Determination Service decision is missing, contact DDSDisability Determination Service and request an update on the disability decision.  If a disability decision has not been determined and it appears the decision may go past 90 days, contact the DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst.  The DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst will work with DDSDisability Determination Service to determine the appropriate action.  The LTCLong Term Care Unit will be notified of status.

Exceptions to the 90-day Processing Time Frame for Initial Applications:

Refer requests for extensions to the DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst.  When an extension is needed 90 days after date of initial application, the person making the request will need to provide the reason(s) for the extension.  Extensions will only be approved when the parent submits a written request stating the reason for the extension and acknowledging and accepting the delay in processing.  Although not required, they may use the Initial Application Extension Request form (MED 36) to make the request.         

• Making the final approval or denial of TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 Medicaid in EISEligibility Information System. The DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst will send the denial notice;
   

• Issuing disability exam coupons if the child needs additional assessments;
   

• Issuing assessment coupons for the care coordinator; and
   

• Communicating with Comagine Health any changes in status, including:
   

  • When a TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 child is approved for HCBHome and Community-Based waiver services;
     

  • When a child becomes eligible for and the family elects to move the child to a different category of Medicaid;
     

  • When a Medicaid case closes for any reason, including failure to submit a DPADivision of Public Assistance renewal; and
     

  • When a TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 application is denied.  

5. The Division of Senior and Disabilities Services (DSDSDivision of Senior and Disabilities Services) is responsible for:

• Completing the ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled-LOCLevel of Care assessment and making ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled-LOCLevel of Care determinations;

• Processing all referrals for initial ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled-LOCLevel of Care determinations and renewals received from Comagine Health;

• Reviewing submission of the completed ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled-LOCLevel of Care packet to ensure it is submitted by the care coordinator, is complete and DSDSDivision of Senior and Disabilities Services is able to make a level of determination within specified timeframes.  If not, DSDSDivision of Senior and Disabilities Services will notify Comagine Health;

• Reporting ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled-LOCLevel of Care approvals or denials to Comagine Health; and

• Certifying all care coordinators including TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 care coordinators.  

Note:

The same regulations are used to determine level of care for IDDIndividuals with Intellectual and Developmental Disabilities waivers that are used for ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled assessments for TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248.  If a child is approved LOCLevel of Care for TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 but denied LOCLevel of Care for HCBHome and Community-Based services, the DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst must be contacted immediately.  

533 D.      CASE PROCESSING

1. Initial Applications

An initial application can come in the following forms:

• MED 4 application or referral from denied MAGIModified Adjusted Gross Income Medicaid application.  If a MED 4 application is submitted or a referral from a denied MAGIModified Adjusted Gross Income Medicaid case is received, send notice M320-Information Needed TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248;

 Tax Equity and Fiscal Responsibility Act, P.L.;  

• Referral from MAGIModified Adjusted Gross Income Medicaid when there is no MAGIModified Adjusted Gross Income Medicaid eligibility and the application includes a disabled child.

If the TEFRA Tax Equity and Fiscal Responsibility Act, P.L. 97-248 process starts from a denied or closed MAGIModified Adjusted Gross Income case, send notice M322-Pend TEFRA Tax Equity and Fiscal Responsibility Act, P.L. 97-248 Disabled Child Denied DKC Denali KidCare.  The family is allowed 15 days to:

• Contact Comagine Health to be connected with a care coordinator for TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 and begin the LOCLevel of Care assessment process;
   

• Return the MED1, MED2, and any accompanying medical information for a disability determination; and
   

• Complete an interview.

The caseworker must follow procedure outlined in ADLTC MS 533 C(4)

Note:

There is currently no ability to qualify for retroactive TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 Medicaid as Alaska does not have a provider that can determine the required retroactive level of care.

2. Actions for NFAcute Care Hospital, Nursing Facility, or Intermediate Care Facility-LOCLevel of Care and IPHInpatient Psychiatric Hospital-LOCLevel of Care

After receiving a referral from DPADivision of Public Assistance by the receipt of the GEN 140B, Comagine Health will send the child's parent or guardian a welcome letter and ask the parent to contact Comagine Health within 30 days for care coordinator referrals. This letter also instructs the parent to contact the Division of Public Assistance if needed.

If the parent contacts a care coordinator and begins the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 assessment process, Comagine Health will:

• Receive  ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled-LOCLevel of Care applications and make appropriate referrals to DSDSDivision of Senior and Disabilities Services (refer to the step below for further ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled processing) and track the process to ensure the care coordinator provides a completed assessment for ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled-LOCLevel of Care, completed COCCost-of-care, and completed Support Plan within required timeframes.  The care coordinators failure to provide these documents will result in denial.
   

• Track the process to ensure the care coordinator provides a completed assessment for NFAcute Care Hospital, Nursing Facility, or Intermediate Care Facility-LOCLevel of Care or IPHInpatient Psychiatric Hospital-LOCLevel of Care, completed COCCost-of-care, and a completed Support Plan within required timeframesPlan of Care.  The care coordinators failure to provide these documents within timeframes will result in denial.

If the care coordinator follows through and provides all documentation in the required timeframes, Comagine Health will make a LOCLevel of Care decision and notify the DPADivision of Public Assistance of approval or denial.

If LOCLevel of Care is denied, Comagine Health notifies the DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst with the following information:

• Name of child,

• The child's care coordinator, and

• Rationale for denial.

The DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst issues the denial letter and sends a copy to the LTCLong Term Care Unit. The LTCLong Term Care Unit completes all actions in EISEligibility Information System.

3. Actions For ICF/ IDDIndividuals with Intellectual and Developmental Disabilities-LOCLevel of Care

If an application for  ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled-LOCLevel of Care is received, Comagine Health will make a referral and provide the following information to DSDSDivision of Senior and Disabilities Services for all new applications and ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled renewals:

• Child's name, date of birth, and SDSSenior Disability Services ID number;
  

• Date required for LOCLevel of Care determination to meet DPADivision of Public Assistance timeframes; and 

• Care Coordination agency and main contact person.

After this initial referral, the following steps occur:

Step 1:

            DSDSDivision of Senior and Disabilities Services sends the care coordinator an email requesting the ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled LOCLevel of Care packet be forwarded to DSDSDivision of Senior and Disabilities Services .

Step 2:

The care coordinator has 30 days to send the ICAPInventory for Client and Agency Planning Evaluation packet to DSDSDivision of Senior and Disabilities Services .

• If the packet is not completed and a level of care determination cannot be made within 90 days, Comagine Health will issue a denial due to not completing the ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled LOCLevel of Care packet.

• If DSDSDivision of Senior and Disabilities Services Division of Senior and Disabilities Services receives all documentation and determines the child does not meet LOCLevel of Care Level of Care, DSDSDivision of Senior and Disabilities Services Division of Senior and Disabilities Services notifies Comagine Health that LOCLevel of Care Level of Care is denied and provides the reason(s) for the denial.  Comagine health notifies the DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst who then issues the denial letter to the parent and notifies the LTCLong Term Care Unit of the denial.  The LTCLong Term Care Unit must close or deny the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 Tax Equity and Fiscal Responsibility Act, P.L. 97-248Medicaid case in EISEligibility Information System.

Step 3:

The care coordinator will contact DSDSDivision of Senior and Disabilities Services if there is difficulty completing the ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled LOCLevel of Care packet within the 30-day period and explain any problems being encountered.  If an extension is needed, DSDSDivision of Senior and Disabilities Services will refer the care coordinator to Comagine Health.  Comagine Health will work with the DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst to provide guidance in completing the ICFIntermediate Care Facility/IDDIndividuals with Intellectual and Developmental Disabilities LOCLevel of CareInventory for Client and Agency Planning Evaluation packet.   

Step 4:

DSDSDivision of Senior and Disabilities Services will notify Comagine Health with the results of the ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled LOCLevel of Care determination.  If the LOCLevel of Care determination results in an approval, LevelComComagine Health will notify the care coordinator, DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst and LTCLong Term Care Unit of the approval.    

If the ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled LOCLevel of Care determination results in a denial, the DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst will:

• Send a letter to the parents with copies to the care coordinator, Department of Law, and DSDSDivision of Senior and Disabilities Services notifying them of the LOCLevel of Care denial; and  
   

• Notify the LTCLong Term Care Unit of the LOCLevel of Care denial to either close or deny the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 Medicaid.

4. Getting Adequate Documentation For ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled LOCLevel of Care Processing

The ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled LOCLevel of Care determination may require information that is not readily available such as a current I.Q. test or psychological evaluation.  

The care coordinator will assist new applicants in scheduling an appointment with a Medicaid provider.  After the appointment is scheduled, the parent must contact the LTCLong Term Care Unit and request a disability exam coupon (DE 25) for the month the appointment is scheduled.  

The care coordinator will assist current TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 recipients in scheduling an appointment with a Medicaid provider.  The evaluation or testing will be billed to Medicaid.

533 E.       TEFRA REVIEWS

Each TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 recipient is subject to the following reviews:

• DPADivision of Public Assistance annual review;
   

• LOCLevel of Care annual review; and
   

• Periodic disability reviews by DDSDisability Determination Service.

Note:  

The LOCLevel of Care, DSDSDivision of Senior and Disabilities Services, and DPADivision of Public Assistance review dates often occur at different times during the eligibility period.  If an LOCLevel of Care or DSDSDivision of Senior and Disabilities Services denial occurs in the middle of an ongoing eligibility period, the caseworker must review for twelve-month continuous eligibility before closing the case.  Refer to Section 515 for policy on continuous eligibility.

1. DPADivision of Public Assistance Reviews

At the time of review, the DPADivision of Public Assistance caseworker must:

• Check for current LOCLevel of Care status;
   

• Check for current disability status;
   

• Review the child's income and resources; and
  

• Check the child's age. If turning 18 years old, they must be referred to apply for SSISupplemental Security Income.

If LOCLevel of Care, disability, and the child's income and resources are within APAAdult Public Assistance standards, approve the Medicaid case.

If LOCLevel of Care is not current, contact Comagine Health for current status, and take the following actions:

• If LOCLevel of Care has been denied the DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst will send the denial notice and inform the LTCLong Term Care Unit to close the Medicaid case; or

• If the parent failed to complete LOCLevel of Care reassessment, the DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst will send the denial notice and inform the LTCLong Term Care Unit to close the Medicaid case; or

• If LOCLevel of Care has not been renewed, but it is determined that there were extenuating circumstances and the DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst has approved an extension, approve Medicaid.  If there is no extension in place, contact the DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst to determine the appropriate action.

If a DPADivision of Public Assistance review is denied for any reason, including failure to renew, notify Comagine Health and the care coordinator of the case closure.  

If the DDSDisability Determination Service review is due, assume continued disability until a new decision is received (see below).

2. DDSDisability Determination Service Review Processing

When a DDSDisability Determination Service file is returned with an approved disability decision, document this in the case notes (CANOCase Notes) and set an alert (ETALEligibility Technician Alerts screen) with a due date 60 days prior to the next disability review.

When a child is due for a disability review, send the parent the MED1 and MED2 forms and EIS Eligibility Information System notice M025, Disability Review Needed, requesting these forms be returned with current medical information within 30 days.  The notice must explain that failure to respond to this request will result in case closure.

The TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 Medicaid case remains open until a new DDSDisability Determination Service decision is received, unless the LOCLevel of Care is denied or the parent fails to renew while waiting for a new DDSDisability Determination Service decision.

• If the DDSDisability Determination Service decision is an approval, document the new Continued Disability Review (CDR) date in the CANOCase Notes.
  

• If the DDSDisability Determination Service decision is denial of disability, provide a copy of the denial to the DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst.  The DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst will issue a closure letter to the parent, the care coordinator, Comagine Health, DSDSDivision of Senior and Disabilities Services and Department of Law.  The LTCLong Term Care unit will close the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 Medicaid case in EISEligibility Information System Eligibility Information before case closure, check for twelve-month continuous eligibility.  See Section 515 for policy on continuous eligibility.

3. LOCLevel of Care Renewal Process

Comagine Health has the primary responsibility for tracking all LOCLevel of Care renewal dates for all three LOCLevel of Care standards.  Comagine Health will maintain a database of open TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 Medicaid cases.  The database will include the LOCLevel of Care, current renewal date, and other identifying information.

For NFAcute Care Hospital, Nursing Facility, or Intermediate Care Facility-LOCLevel of Care and IPHInpatient Psychiatric Hospital-LOCLevel of Care:

Comagine Health will send a letter 90 days prior to the month the renewal is due notifying the care coordinator that a child's LOC Level of Care is due and request renewal paperwork.  When the care coordinator submits the Support Plan, COCCost-of-care, and LOCLevel of CareLevel of Care documentation, Comagine Health will approve or deny continued LOCLevel of CareLevel of Care.  Comagine Health will email the DPADivision of Public Assistance caseworker with the approval decision for the caseworker to take appropriate action.  Comagine Health will email the DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst with the denial decision.  The DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst will send the denial notice and notify the LTCLong Term Care Unit to close the Medicaid case.

For ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled-LOCLevel of Care:

Ninety (90) days prior to the month of renewal, Comagine Health will make a referral to DSDSDivision of Senior and Disabilities Services for an ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled LOCLevel of Care determination.  Comagine Health will also notify the care coordinator indicating that an ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled LOCLevel of Care referral has been made.

When the ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled LOCLevel of CareInventory for Client and Agency Planning Evaluation determination is completed and a LOCLevel of Care decision rendered, DSDS Division of Senior and Disabilities Services will forward the results to Comagine Health.  Comagine Health will review COCCost-of-care and Support Plan status and notify DPADivision of Public Assistance of LOCLevel of Care determination.  If the child does not meet LOCLevel of Care, the DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248/Specialized Medicaid PAAPublic Assistance Analyst will issue a closure letter to the parent.  The LTCLong Term Care Unit will take appropriate action to close the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 Medicaid case in EISEligibility Information System.

533 F.        EISEligibility Information System INFORMATION