016.20.02 Ark. Code R. § 022 - Medical Services Policy MS 27000 - 27075; TEFRA Waiver / Home Care for Children; Appendix P - TEFRA Premium Schedule
TEFRA Waiver is a Section 1115(a) demonstration waiver that replaces the previous TEFRA eligibility category. This new category imposes cost sharing requirements on children age 18 and under who are otherwise eligible for Medicaid under Section 134 of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA).
TEFRA, as amended by OBRA of 1987, provides for coverage of certain disabled children in the home if they would qualify for Medicaid as residents of a Title XIX Institution, such as a nursing home or ICF/MR Facility.
TEFRA Waiver is a Medicaid category that enables children to have care in their homes rather than in an institution. Children who live in institutions or receive extended care in institutions are not eligible in the TEFRA category. Recipients of TEFRA Waiver will receive the full range of Medicaid benefits and services. There will be no cap on the number of children covered by the program.
Cost sharing measures will be based on the total gross income of the custodial parent(s) as reflected on the most recently filed IRS Federal Tax Return.
Families of children eligible for TEFRA Waiver who are covered by insurance should not drop their existing coverage as it will cause the child to be ineligible for TEFRA Waiver benefits for a period of six (6) months from the date the insurance is dropped.
The following eligibility requirements must be met for a child to be eligible for TEFRA Waiver:
The six-month period of ineligibility will apply unless one of the following conditions is met:
The health insurance is a non-group or non-employer sponsored plan.
The health insurance was lost through termination of employment for any reason, including voluntarily quitting.
The health insurance was lost through no fault of the custodial parent(s), guardian or custodian. For example, the employer ceases to provide employer sponsored health insurance, the insurance was carried by the non-custodial parent, and the non-custodial parent dropped it, the maximum benefit limit for the child has been reached, etc.
All waiver recipients with annual gross family income over $25,000 will pay a monthly premium. The amount of the premium will be determined based on the custodial parent(s) total income as reported on the applicable Federal Income Tax Return (e.g., line 22 of the 2001 version of form 1040 or line 15 of the 1040 A) less the following deductions:
Six hundred dollars ($600) per child, biological or adopted, including the waiver child, who lives in the home of the waiver child and is listed as a dependent child on the applicable Federal Income Tax Return of the parents.
Excess medical and dental expenses as itemized on Schedule A of the Federal Income Tax Return of the parents, (e.g., line 4 on the 2001 version of Schedule A).
Example: Family consists of 5 people - mom, dad, waiver child and 2 minor siblings, living in the home. Total Income on last year's Federal Income Tax Return showed $65,417.48. Excess medical and dental on Schedule A showed $9,463.25. All children in the home were included on the return. The budget is:
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If the custodial parent alleges that household income has decreased significantly since filing the Federal Income Tax Return, additional verification can be submitted to determine current income.
Note: A stepparent living in the home will be considered a custodial parent and his or her income will be included when determining the premium amount.
See Appendix P for the amount of premiums to be paid. The maximum annual premium amount to be paid by any family is $5,500. Families having more than one child receiving TEFRA Waiver benefits will pay only one premium for all covered children. There will be no increase in premium amount for additional Waiver children.
The caseworker will key the income, along with the names of the TEFRA children living in the home to a Web application. The system will figure the premium amount due for the household.
Premiums will begin in the month after eligibility is approved. The premium will be charged on a monthly basis and will not be pro-rated. Income will be reviewed annually for calculation of the premium, or when there is a change that will make a difference of more that 10% in annual household income. An adjustment can be made to the premium during the year if a significant change is reported in excess of 10% of the expected annual income. Verification of the income change must be provided. Income that fluctuates due to seasonal employment will not affect the monthly premium. The premium can only be adjusted a maximum of once every six months.
Payments must be made through monthly bank drafts or quarterly payments in advance. For new recipients, premiums will be applied beginning with the month after the month of approval.
The TEFRA Premium Unit will collect the TEFRA Medicaid premium payments and send the premium invoices to TEFRA households. When a TEFRA case is approved, the TEFRA Premium Unit will send a TEFRA Premium Payment Selection Form to the recipient giving the option of authorizing an automatic bank draft or making quarterly payments in advance. Regardless of payment choice, everyone will be required to pay for the first two months' premiums by check. The check must be sent in with the Payment Selection Form. The draft or quarterly payment will begin with the third month after the month of approval.
For those individuals who choose to pay through monthly bank drafts, the TEFRA Premium Unit will draft the account for the third month after approval and the following months. Each draft will be made on the first day of the covered month. The TEFRA Premium Unit will send monthly invoices that the bank account has been drafted.
For those who choose quarterly payments, the individual must initially pay for the month after the month of approval and the following month in advance by check, after which the TEFRA Premium Unit will send monthly invoices requesting premium payment in the month prior to the covered quarter.
If eligibility ends during the quarter, any premiums already paid for months after the month of closure will be reimbursed. Whether paying by monthly bank drafts or through quarterly payments, if eligibility ends in the middle of the month in which payment has been made, the premium will be prorated and the family will be reimbursed for the partial month.
Failure to provide the Payment Selection Form or make the two month initial payment will cause the child to be ineligible, and the case will be closed after proper advance notice. For ongoing cases, if the premium is not paid for three months, advance notice will be sent and the case will be closed. The TEFRA Premium Unit will notify the county office if the Payment Selection Form is not received.
Monthly aged reports will be sent to each county showing the cases with overdue premiums and the number of payments in arrears. The caseworker will send a 10-day advance notice to each case showing three months of non-payment, advising that the case will be closed if payment is not made. At the end of the notice period, if payment of the premiums has not been made, the case will be closed.
Applications will be available at local DHS offices or by mail, through hospitals, including Arkansas Children's Hospital, and Federally Qualified Health Centers. Information will be available through First Connections, Division of Developmental Disabilities (DDS) Services Coordinators and providers. Information will also be available on the DHS/DMS website.
Applications will be made by the adult responsible for the care of the child and will be processed in the child's county of residence.
TEFRA Waiver applicants should be screened for ARKids A eligibility and if found eligible, approved in the ARKids A category. ARKids A provides the full range of Medicaid benefits and services, has no co-payments, and can generally be approved much more quickly than TEFRA as no disability or medical necessity determination is required. If the family income is under the income limit for ARKids B, the ARKids B coverage package including co-pays should also be explained so that parents can make an informed choice between ARKids A, ARKids B and TEFRA.
In addition to the application form DCO-777 or DCO-215, sections I and II of the DMS-2602 must be completed. When the parent or guardian's signature has been obtained at the bottom of Page 1 of the DMS-2602, the Physician's Assessment Form will be given to the individual to be completed by the child's physician. If disability is to be established by MRT, forms DCO-106, DCO-107, DCO-108 and DCO-81(s), if needed, will also be completed. The TEFRA Waiver Brochure, PUB-405, should also be given to the applicant explaining the medical determination process and the premium process.
of Premiums
When the TEFRA case is closed due to non-payment of premiums, a new application must be made before eligibility can resume. Eligibility will be redetermined at the time the new application is made.
If the case has been closed less than 12 months because of failure to pay premiums, the past due premiums must be paid in full before the child can be re-approved for TEFRA Waiver services.
If a case is closed 12 months or more due to failure to pay premiums, payment of the past due premiums will not be required to reopen the case.
With the exception of the Appropriateness of Care and Cost Effectiveness requirements, eligibility will be determined by the caseworker in the same manner as AD Long Term Care cases.
A child who would not be eligible or potentially eligible for Medicaid in an institution cannot be considered for TEFRA. If the child's countable income is less than the current LTC income limit and the child's countable resources are less than $2,000.00, he/she will meet the TEFRA income and resource requirements. Parental income and resources will be disregarded when determining eligibility. However, parental income will be considered when calculating the monthly premium amount.
Some children who receive SSI may intermittently lose their SSI due to fluctuating parental income and may be eligible for TEFRA in the non-SSI months. In these instances, the caseworker must redetermine TEFRA eligibility for each month in which the child is not SSI eligible. Children with alternating TEFRA and SSI eligibility will not be assessed a premium for the TEFRA months.
If fluctuating parental income causes a child's SSI eligibility status to change from month to month, and less than 10 months have passed since the last full TEFRA Waiver certification or reevaluation, only a new DCO-777 or DCO-215 and a redetermination of income and resource eligibility are required to reopen the TEFRA Waiver case. Redetermination of other eligibility factors will not be required.
To qualify for TEFRA, a child must be considered disabled according to the SSI regulations that govern children's disabilities. If a child received SSI within one year prior to making TEFRA Waiver application, but was terminated for reasons other than lack of disability, (e.g. parental income or resources), documentation will be obtained for the case record. The child will be considered disabled based on the previous SSA disability determination.
A disability decision made by SSA on a specific disability is controlling for that disability, until the decision is changed by SSA. Therefore, the DCO-106 Disability Worksheet will be completed to determine if MRT will make a disability determination for a child who has not received SSI within the year prior to making TEFRA application.
The disability guidelines at MS 3322 will be followed. If MRT is to make a disability determination, the caseworker will forward the required forms to MRT.
A MRT disability redetermination may or may not be necessary at the time the TEFRA case is reevaluated. A reexamination by MRT is necessary when indicated on the DCO-109, or one year after the initial certification for TEFRA, when the certification was made based on a previous SSI determination of disability and there has been no SSI payment or subsequent redetermination by SSA.
Example: A child received SSI for 6 months in 2001, then lost SSI due to increased parental income. The parent applies for TEFRA in September 2001, and the case is certified in November 2001 based on the previous SSI disability determination. The child has not received SSI benefits since certified. At the annual reevaluation in 2002, a MRT and disability determination is required.
A review by MRT is also necessary if the caseworker becomes aware of significant improvement and/or employment at or near the SGA level (Re. MS 3323.2).
Effectiveness
When the completed DMS-2602 is returned to the county office by the child's physician, the DMS-2602 and DMS-2603 and any medical records that have been submitted will be sent to DMS, Attention: TEFRA Committee, Slot S-412, P.O. Box 1437, Little Rock, AR 72203. The county office will maintain copies of all records mailed. The TEFRA Committee is coordinated by the Medical Director for the Division of Medical Services.
DMS and the TEFRA Committee will determine if the applicant meets the Cost Effectiveness and Appropriateness of Care criteria. If these are met, and if the referral is otherwise appropriate, DMS will complete Parts IV and V of the DMS-2602 and Parts III and V of the DMS-2603. DMS and the TEFRA Committee will determine Medical
Necessity and will be responsible for returning the DHS-704, DMS-2602 and DMS-2603 to the county office for final approval or denial, pending MRT decision if applicable.
NOTE: An application will not be denied solely for failure of the physician to complete and return the DMS-2602 until an effort has been made to assist the client in obtaining the completed DMS-2602. The caseworker will remind the applicant of the necessity of the form and of his/her responsibility for obtaining the form. Assistance will be given whenever possible.
The caseworker will have 45 days to determine TEFRA eligibility for the child, or 90 days if an MRT decision is required.
If at any point in the eligibility determination the child fails to meet eligibility requirements, the application will be denied.
The DMS-2603, Summary of Case Eligibility /TEFRA will be reviewed for documentation that each eligibility requirement has been met.
The begin date for TEFRA Waiver eligibility will be the date of application, unless retroactive coverage is needed. If needed, the eligibility begin date can be as early as three months prior to the date of application, provided all eligibility requirements are met.
A child cannot be approved for retroactive coverage before the onset of his/her disability as he/she would not meet the TEFRA disability or medical necessity requirements prior to the onset of disability. A child who had been residing in an institution would not be eligible for any retroactive coverage while still residing in the institution as TEFRA Waiver coverage is for non-institutionalized children only. For any retroactive coverage needed, it can be assumed that medical necessity, appropriateness of care and cost effectiveness have been met unless there is evidence to the contrary.
After approving a child under the TEFRA Waiver, the caseworker will notify DMS and the TEFRA Committee of the certification by sending a memorandum or copy of the DCO-700 to P.O Box 1437, Slot S-412, Little Rock, AR 72203.
DMS and the TEFRA Committee will be responsible for monitoring Cost Effectiveness on an annual basis. When it is determined that the cost of home care exceeds the cost of institutional care, DMS will notify the caseworker of the change via memorandum. The caseworker will send a 10-day advance notice on the DCO-700 and close the case at the end of the notice period.
TEFRA Waiver cases will be reevaluated every 12 months. To insure that reevaluations are completed by the end of the twelfth month, the reevaluation process should be started in the 10th month from the date of the last approval or reevaluation.
If the child's SSI eligibility has fluctuated due to changing parental income since the last certification or reevaluation, Medical Necessity, Cost Effectiveness and Appropriateness of Care will not be determined until the case is in, or nearing, the 10th month since completion of the last TEFRA reevaluation or certification.
At reevaluation, all eligibility factors, including appropriateness of care and cost effectiveness, will be redetermined. Disability will be redetermined as specified at MS 27050. All forms completed for the initial application, including the DMS-2602 and DMS-2603, must be completed at reevaluation. In addition, the premium amount will be redetermined at reevaluation. If the premium changes, the parent will be notified of the new amount by the TEFRA Premium Unit.
When a change occurs that affects eligibility, the caseworker will notify DMS and the TEFRA Committee advising when the closure will be made. A 10-day advance notice will be given on the DCO-700, unless advance notice is not required (Re. MS 3633) and a copy of the DCO-700 or a memorandum will be sent to DMS.
APPENDIX P TEFRA Premium Schedule
|
Family Income |
Monthly Premiums |
|||
|
From |
To |
% |
From |
To |
|
$0 |
$25,000 |
0.0% |
$0 |
$0 |
|
$25,001 |
$50,000 |
1.00% |
$21 |
$42 |
|
$50,001 |
$75,000 |
1.25% |
$52 |
$78 |
|
$75,001 |
$100,000 |
1.50% |
$94 |
$125 |
|
$100,001 |
$125,000 |
1.75% |
$146 |
$182 |
|
$125,001 |
$150,000 |
2.00% |
$208 |
$250 |
|
$150,001 |
$175,000 |
2.25% |
$281 |
$328 |
|
$175,001 |
$200,000 |
2.50% |
$365 |
$417 |
|
$200,001 |
111 |
2.75% |
$458 |
$458 |
The maximum premium is $5,500 per year ($458 per month) for income levels of $200,001 and above.
The premiums listed above represent family responsibility. The premiums will not increase if a family has more than one TEFRA Waiver child.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.