TEFRA Care Coordinator Training. October 2008 Terry Hamm DPA Long Term Care Coordinator

Transcription

1 TEFRA Care Coordinator Training October 2008 Terry Hamm DPA Long Term Care Coordinator

2 Who are TEFRA Children? TEFRA Children Are: Children whose parental income is over the Denali KidCare income limits Children who meet a definition of Social Security Disability (if not for parental income/resources they would be eligible for SSI) and Children who meet one of three Level-of of-care (LOC) categories Children whose personal income and resources are within Special Income Medicaid limits

3 The TEFRA Players Division of Public Assistance Qualis Health The Division of Senior and Disability Services (DSDS) Care Coordinators Disability Determination Services (DDS) Parent(s)

4 Eligibility Requirements Child s Income and Resources: Income $1656 or less per month Liquid resources $2000 or less Meet a Social Security definition of disability as determined by Disabilty Determination Services (DDS) Live in the parental home Meet one of three possible LOC categories: Intermediate Care Facility for the Mentally Retarded (ICF/MR) Nursing Facility (NF) Inpatient Psychiatric Hospital (IPH)

5 TEFRA LOC Categories ICF/MR: Uses the Inventory for Client and Agency Planning (ICAP) to determine LOC DSDS completes the ICAP evaluations NF: Equivalent LOC to Children with Complex Medical Conditions (CCMC)Waiver( IPH: Unique to TEFRA Children often move between TEFRA and Child Only DKC

6 Application Process - New Parent(s) ) must complete and submit to DPA: The MED 4 Application for Medical Assistance Adults and Children with Long Term Care Needs Complete MED 1 Child Health Questionnaire Sign MED 2 Medical Release of information Gather as much pertinent medical records for a disability determination Submit completed application packet and complete an interview with the DPA caseworker Contact Qualis Health for referral to a Care Coordinator Select a Care Coordinator and cooperate in the completion of LOC process

7 Application Process Referral from Denied DKC Parent(s) ) must complete and submit to DPA: Response to DPA Notice PEND TEFRA DISABLED CHILD DENIED DKC Complete MED 1 and MED 2 forms Gather pertinent information for disability determination Submit all requested information to DPA caseworker and complete an interview Contact Qualis Health for Care Coordinator referral Cooperate with Care Coordinator for LOC process

8 DPA Caseworker Completing the financial and resource determination Submitting the disability packet to DDS for disability determination and tracking the Continuing Disability Review (CDR) dates Faxing GEN140B to QUALIS Health Issuing coupons if the child needs additional assessments for LOC assessment

9 DPA Caseworker cont. Issuing assessment coupons for the care coordinator Making the final eligibility decision Communicating changes to QUALIS: When HCB Waiver is approved When child moves to another category of Medicaid When the Medicaid case closes for any reason When a TEFRA application is denied When TEFRA case is opened after initial DDS denial is reversed

10 QUALIS Health Referring families to care coordination agencies and the DPA caseworker Completing an initial screening to see if family should be referred to DKC Completing a LOC screening Referring potential ICF/MR and ICF/MR renewals to DSDS

11 QUALIS Health cont. Approving LOC, POC, and COC and tracking renewal dates for NF and IPH LOC Approving POC, and COC for ICF/MR after DSDS has determined LOC LOC determination and tracking LOC renewal date Notifying care coordinators when yearly LOC renewal is due

12 QUALIS Health cont. Notifying parents when yearly LOC renewal is due Notifying the DPA caseworker when LOC, POC, and COC is approved. This will come in the form of an containing the following: Name of child Approved or denied If approved the LOC and renewal date Name of care coordinator

13 DSDS Beginning January 1, 2007 DSDS took over the following responsibilities: Reviewing all documentation for the Other Mental Retardation Category Determining LOC for all children under 3 years of age Making all TEFRA ICF/MR LOC decisions once the ICAP assessment is completed

14 TEFRA ICF/MR LOC Processing For children under 3 Years of Age, follow the steps below: 1. Contact Qualis Health so referral can be made to the DPA Long Term Care Coordinator 2. Obtain the child s most recent developmental assessment (i.e. ILP) and supporting medical documentation with any diagnoses 3. Mail all documentation directly to DSDS

15 TEFRA ICF/MR LOC Processing For children age 3 and older, follow the steps below: 1. Wait for Qualis Health to make a referral to DSDS 2. After a referral is made DSDS will send notification and request documentation 3. Submit ICAP contact sheet and supporting documentation to DSDS within 15 days of receiving notification 4. If documentation is insufficient or if a determination for Other Mental Retardation Related Conditions is needed DSDS will review the documentation and determine if child meets a diagnosis to proceed with ICAP

16 Care Coordination Agency Completing POC, COC, and LOC documentation for NF and IPH for both new applications and renewals, and submitting the information to QUALIS Completing ICAP packet for both new applications and renewals, and submitting to DSDS Making appropriate referrals to DPA for completion of DPA application

17 Role of DDS Completes State-only disability decisions for the Division of Public Assistance using Federal Social Security Regulation For children the Federal Regulations used are: Functional Equivalents: 20 CFR , 924a, 924b, 925, 929* Medical Listings: 20 CFR Pt. 404, Subpt.P,, App.1* *These are the same listings used when making SSI disability decisions

18 How a Child Meets Disability Child must meet a medical listing or Child must be considered Marked in two areas of life functioning or Extreme in one area The areas of life functioning are: Acquiring and Using Information Attending and Completing Tasks Interacting and Relating to Others Moving about and Manipulating Objects Caring for Yourself Health and Physical Well-Being

19 Helpful Information for Disability and LOC Determinations Current Individual Education Plan (IEP) Current Infant Learning Assessment Current Medical records and pertinent lab reports Letters from teachers and counselors Records from additional support programs (I.e. On-Target)

20 Role of Parent(s) Completing the yearly LOC renewal Completing the yearly DPA renewal Completing paperwork for periodic Disability Reviews for DDS Medicaid is always payer of last resort so it is vital that all private insurance coverage is reported to the DPA caseworker

21 Frequently Asked Questions

22 Does TEFRA Medicaid offer additional coverage? No. TEFRA Medicaid provides the same coverage as Denali KidCare,, Family Medicaid, or as a child receiving SSI related Medicaid. No additonal services are paid for by TEFRA Medicaid.

23 A TEFRA child is going to turn 18, what should the parent(s) do? TEFRA Medicaid can be authorized through the month of a child s 19 th birthday. However, it is highly recommended that the parent(s) ) should apply for Supplemental Security Income (SSI) in the month child turns 18 years of age. When SSI is approved the child s Medicaid coverage can be converted to adult disability Medicaid.

24 A child is on SSI, should TEFRA be pursued? No. A child receiving SSI payments is automatically eligible for Medicaid coverage. SSI child Medicaid cases are processed and maintained in the Denali KidCare office. However, there are times when an SSI child becomes ineligible for SSI due to parental income and/or resources. When this happens the Denali KidCare office will see if the child remains eligible for Denali KidCare.. If the parental income is also over the Denali KidCare limits the Denali KidCare worker will make a referral to the TEFRA worker.

25 If a former TEFRA child is denied LOC by DSDS for the CCMC or MRDD waiver will TEFRA be reopened? The same criteria is used for TEFRA LOC as is used for CCMC and MRDD LOC; therefore, TEFRA would not be reopened. However, at times a child may have dual diagnosis and could possibly meet another LOC. For example, a child who does not meet ICAP may meet an IPH LOC for TEFRA.

26 TEFRA vs. Waivers TEFRA Requires LOC decision using 7 AAC , 185, 190 or ICAP for ICF/MR Requires disability decision by DDS Resource limit of $2000 and monthly income limit of $1656 Provides basic Medicaid coverage Waiver Requires LOC decision using 7 AAC , 185, 190 or ICAP for ICF/MR Requires the child be eligible for a category of Medicaid Disability decision is beneficial Provides additional waiver supports for the child and family

27 Important Contact Numbers Qualis Health: In Anchorage: Outside Anchorage: DPA TEFRA Caseworkers: Fairbanks and North Slope: Melanie Best or Remainder of State (based in Anchorage): Arlene Phillips (Alpha A-J) A or /4372 or Sarah Harlamert (Alpha K-Z) K or / /4372

28 Questions? Terry Hamm DPA Long Term Care Coordinator