TEFRA Children Overview
Frequently Asked Questions
Question 1: What is TEFRA?
Answer: Under Section 134 of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), (P.L.97-248), states have the option to make Medicaid benefits available to children with physical or mental disabilities who would not ordinarily be eligible for Supplemental Security Income (SSI) benefits because of their parent's income or resources are too high. TEFRA allows children who are eligible for institutional services to be cared for in their homes. (They don’t have to be in an institution).
Question 2: I’ve heard about the Katie Beckett Waiver, is TEFRA the same thing?
Answer: TEFRA is sometimes confused with the Katie Beckett Waiver, named after the child whose situation inspired it. Under Medicaid, TEFRA is a state plan option, not a Katie Beckett Waiver. TEFRA is Medical Assistance coverage for certain children under age 19 who have disabling conditions and live at home. This program enables children with disabilities or special health care needs to be cared for at home instead of in an institution. Only the child’s income and resources are used in determining financial eligibility. The cost of care at home compared to the cost in an institutional setting is also used in determining eligibility.
Question 3: Who is eligible for TEFRA?
Answer: To be eligible, a child must meet the following requirements:
- Be under age 19;
- Live at home;
- Meet the SSI definition of disability;
- Have gross monthly income at or below $1737.00 for 2005 and countable resources at or below $2,000.00 (only the child's income and resources are counted);
- Meet an institutional level of care. The three levels of care are: intermediate care for the mentally retarded (ICF-MR), nursing facility (skilled or intermediate care) or hospital care. Meeting a level of care does not mean a child must be institutionalized;
- It must be appropriate to provide care to the child at home; and
- The estimated cost of caring for the child outside the institution cannot exceed the estimated cost of treating the child in the institution.
A child who meets these requirements may be eligible for the full range of Medicaid covered services.
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Question 4: What is meant by ‘disability?’
Answer: An individual under 19 years of age shall be considered to have a disability, if that individual has a medically determinable physical or mental impairment, which results in marked and severe functional limitations, and which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.
Question 5: What is meant by ‘institutional level of care'?
Answer: Institutional level of care means a person/child needs a level of care that is normally provided in an institution. For TEFRA the three levels of care are:
- Intermediate Care Facility for Persons with Mental Retardation(ICF/MR,)
- Nursing Facility, or
- Acute Care Hospital
Question 6: Where can I apply?
Answer: You can apply at your local county office of Department of Human Services.
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Question 7: Will my doctor have to complete a form?
Question 8: What services will my child receive?
Answer: Depending upon the person's needs, services may include:
- child health/EPSDT
- dental care
- emergency and non-emergency transportation
- inpatient and outpatient treatment
- medical equipment
- occupational therapy
- physical therapy
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Question 9: What services will my child not be eligible for?
Answer: This is not all inclusive but lists a few services that are not available through TEFRA:
- respite care
- environmental accessibility adaptations
- architectural modifications
- habilitation services
- family training
- supported employment
- services not covered by Oklahoma’s Medicaid State Plan
Question 10: Will my child be enrolled in SoonerCare, the state’s managed care system?
Answer: Yes, unless your child already has coverage with an HMO, then he or she will be in Medicaid fee for service.
Question 11: Where can I find out more information about SoonerCare?
Answer: Phone: (800) 987-7767 Toll Free
(405) 522-7171 Oklahoma City Area
(405) 522-7179 TDD/TTY
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Question 12: Is there a waiting list for TEFRA?
Question 13: If my child is eligible for TEFRA, can I still apply for the Oklahoma Department of Human Services Developmental Disabilities Home and Community Based Waiver?
Question 14: If my child is currently on the waiting list for DDSD waiver services, will he/she remain or drop off after becoming eligible for TEFRA?
Answer: Your child will remain on the list.
Question 15: How long will my child be certified under TEFRA?
Answer: Your child can be certified for up to 12 months.
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Question 16: Does my child need to apply for SSI?
Answer: Yes, to do this call the Social Security Administration at (800) 772-1213 and talk to the Teleservice representative about your child’s eligibility for Supplemental Security Income (SSI). Based on the information you provide to the Teleservice representative one of two things will happen.
- Teleservice representative will issue an informal denial letter stating that your child is not eligible for SSI and list the reasons why. OR
- If your child was potentially eligible for SSI, the Teleservice representative would send a message to your local office, and they would contact your about filing a formal claim.
Question 17: Where can I get more information?
Answer: Please call SoonerCare Helpline (800) 987-7767, (800) 757-5979 TDD/TTY.
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