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 a 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 MS 515 for policy on continuous eligibility.

1. DPA Reviews

At the time of renewal, 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 SSI.

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 Project Assistant 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 Project Assistant 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 by the LTCLong Term Care caseworker that there were extenuating circumstances and the care coordinator or parent has requested an extension, approve Medicaid. 

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. DDS Review Processing

When a DDSDisability Determination Service 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 EISEligibility 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 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 (CDRContinuing Disability Review) date in the CANOCase Notes.

• If the DDSDisability Determination Service decision is denial of disability, the caseworker must email a copy of the DDSDisability Determination Service denial letter to the DPADivision of Public Assistance Policy email address hss.dpa.policy@alaska.gov and the DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 Project Assistant will issue a closure letter to the parent, the care coordinator, Comagine health, DSDSDivision of Senior and Disabilities Services, and the 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.  Before case closure, check for TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 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 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 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 LOCLevel of Care is due and request renewal paperwork. When the care coordinator submits the Support Plan, COCCost-of-care, and LOCLevel of Care documentation, Comagine Health will approve or deny continued LOCLevel 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 Project Assistant with the denial decision.  The DPADivision of Public Assistance TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 Project Assistant will send the denial notice and notify the LTCLong Term Care 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 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 Care determination is completed and a LOCLevel of Care decision rendered, DSDSDivision 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 the 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 Project Assistant will issue a closure notice 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.