533 E.       TEFRA REVIEWS

Each TEFRA recipient is subject to the following reviews:

• DPA annual review,

• LOC annual review, and 

• Periodic disability reviews by DDS.

Note:

The LOC, DSDS, and DPA review dates often occur at different times during the eligibility period. If a LOC or DSDS 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 MS 515 for policy on continuous eligibility.

1. DPA Reviews

At the time of renewal, the DPA caseworker must:

• Check for current LOC 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 SSI.

If LOC, disability, and the child's income and resources are within APA standards, approve the Medicaid case.

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

• If LOC has been denied, the DPA TEFRA Specialized Medicaid PAA will send the denial notice and inform the LTC unit to close the Medicaid case, or

• If the parent failed to complete LOC reassessment, the DPA TEFRA Specialized Medicaid PAA will send the denial notice and inform the LTC unit to close the Medicaid case, or

• If LOC has not been renewed, but it is determined that there were extenuating circumstances and the DPA TEFRA Specialized Medicaid PAA has approved an extension, approve Medicaid. If there is no extension in place, contact the DPA TEFRA Specialized Medicaid PAA to determine the appropriate action.

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

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

2. DDS Review Processing

When a DDS file is returned with an approved disability decision, document this in the case notes and set an alert 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 MED 1 and MED 2 forms and EIS 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 TEFRA Medicaid case remains open until a new DDS decision is received, unless LOC is denied or the parent fails to renew while waiting for a new DDS decision.

• If the DDS decision is an approval, document the new Continued Disability Review (CDR) date in the CANO.

• If the DDS decision is denial of disability, provide a copy of the denial to the DPA TEFRA Specialized Medicaid PAA. The DPA TEFRA Specialized Medicaid PAA will issued a closure letter to the parent, the care coordinator, Comagine health, DSDS, and Department of Law. The LTC unit will close the TEFRA Medicaid case in EIS. Before case closure, check for twelve-month continuous eligibility. See MS 515 for policy on continuous eligibility.

3. LOC Renewal Process

Comagine Health has the primary responsibility for tracking all LOC renewal dates for all three LOC standards. Comagine Health will maintain a database of open TEFRA Medicaid cases. The database will include the LOC, current renewal date, and other identifying information.

For NF-LOC and IPH-LOC:

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 is due and request renewal paperwork. When the care coordinator submits the Support Plan, COC, and LOC documentation, Comagine Health will approve or deny continued LOC. Comagine Health will email the DPA caseworker with the approval decision for the caseworker to take appropriate action. Comagine Health will email the DPA TEFRA Specialized Medicaid PAA with the denial decision. The DPA TEFRA Specialized Medicaid PAA will send the denial notice and notify the LTC unit to close the Medicaid case.

For ICF/IDD-LOC:

Ninety (90) days prior to the month of renewal, Comagine Health will make a referral to DSDS for an ICF/IDD LOC determination. Comagine Health will also notify the care coordinator indicating that an ICF/IDD LOC referral has been made.

When the ICF/IDD LOC determination is completed and a LOC decision rendered, DSDS will forward the results to Comagine Health. Comagine Health will review COC and Support Plan status and notify DPA of the LOC determination. If the child does not meet LOC, the DPA TEFRA Specialized Medicaid PAA will issued a closure notice to the parent. The LTC unit will take appropriate action to close the TEFRA Medicaid case in EIS.