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 NF-LOC and IPH-LOC 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 NF-LOC and IPH-LOC cases,

• Making the Support Plan and COC review determinations for ICF/IDD-LOC cases and maintaining a record of the LOC approval by DSDS, and

• Emailing the DPA LTC unit, the DPA TEFRA Specialized Medicaid PAA, and Care Coordinators when LOC is approved or emailing the DPA TEFRA Specialized Medicaid PAA when LOC is denied.

2. The Care Coordination Agency is responsible for:

• Completing and submitting the Support Plan, COC, and LOC documentation to Comagine Health for all NF-LOC and IPH-LOC cases,

• Completing the Support Plan and COC for ICF/IDD-LOC cases and working with DSDS in the development and completion of the Inventory for Client and Agency Planning (ICAP) assessment packet,

• Submitting all necessary information to Comagine Health and DSDS,

• Explaining to parents that they must complete a DPA application with a referral to the appropriate DPA office, and 

• Contacting parents when the annual LOC reassessment is due.

Note:

TEFRA care coordinators only receive payment for screening, initial assessment, and yearly reassessment for LOC and the Support Plan. TEFRA 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 DPA 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 DDS 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 APA MS 425-3(C) and Admin Procedures MC 115-9 for policy and procedures on disability determinations.

4. DPA is responsible for:

• Sending the TEFRA welcome letter (MED 16) and  TEFRA Medicaid for Disabled Children at Home brochure (MED 15) to the parent or guardian whenever an application is received for TEFRA Medicaid. This must be documented in the CANO,

Note:

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

• Completing the Medicaid eligibility determination,

• Submitting the disability packet to DDS for initial applications, tracking disability review dates, and submitting a disability review at the application 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. TEFRA 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 - TEFRA notice, to pend a TEFRA application. Send a copy of this notice to the care coordinator.

• On day 61:

1. If the LOC decision is missing, notify Comagine Health and request a LOC update. If LOC has not been determined and it appears the decision may go past 90 days, contact the DPA TEFRA Specialized Medicaid PAA. The DPA TEFRA Specialized Medicaid PAA will work with Comagine Health to determine the appropriate action. The LTC unit will be notified of status.

2. If the DDS decision is missing, contact DDS 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 DPA TEFRA Specialized Medicaid PAA. The DPA TEFRA Specialized Medicaid PAA will work with DDS to determine the appropriate action. The LTC unit will be notified of status.

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

Refer requests for extensions to the DPA TEFRA Specialized Medicaid PAA. 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 TEFRA Medicaid in EIS. The DPA TEFRA Specialized Medicaid PAA 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 TEFRA child is approved for HCB 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 DPA renewal, and

• When a TEFRA application is denied.

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

• Completing the ICF/IDD-LOC assessment and making ICF/IDD-LOC determinations,

• Processing all referrals for initial ICF/IDD-LOC determinations and renewals recevied from Comagine Health,

• Reviewing submission of the completed ICF/IDD-LOC packet to ensure it is submitted by the care coordinator, is complete, and DSDS is abled to make a level of determination within specified time frames. If not , DSDS will notify Comagine Health,

• Reporting ICF/IDD-LOC approvals or denials to Comagine Health, and

• Certifying all care coordinators, including TEFRA care coordinators.

Note:

The same regulations are used to determine level of care for IDD waivers that are used for ICF/IDD assessments for TEFRA. If a child is approved LOC for TEFRA but denied LOC for HCB waiver services, the DPA TEFRA Specialized Medicaid PAA must be contacted immediately.