Medical Assistance under the TEFRA option for children with disabilities
Medical Assistance (MA) under the TEFRA option helps children with disabilities qualify for MA, even if their family’s income is too high to qualify. TEFRA is short for the Tax Equity and Fiscal Responsibility Act, the federal law that set the rules for this option.
To qualify for MA under the TEFRA option, a child must meet all the following requirements:
Be otherwise ineligible for MA when parents’ income is counted
Be under age 19
Live with at least one biological, adoptive or stepparent
Be certified disabled by the Social Security Administration (SSA) or the State Medical Review Team (SMRT)
Need a level of care to stay at home that is similar to the level of care provided in a hospital, nursing home or intermediate care facility for people with developmental disabilities (SMRT makes the level-of-care determination).
The TEFRA option helps children with disabilities get Medical Assistance (MA) coverage by only counting the child’s income, not the whole family’s income.
If the child’s income is higher than this limit, the child may still qualify by meeting a spenddown. A spenddown is like a deductible for medical expenses. See information about spenddowns in What is a Spenddown (DHS-3017-ENG) (PDF).
If your child qualifies for MA under the TEFRA option, the child will receive the same coverage as children enrolled in MA. This includes doctor’s visits, prescriptions and hospital stays. In addition, it can cover Community First Services and Supports (CFSS) (DHS-8477A-ENG) (PDF) which is a Minnesota health care program that allows flexible options for those requiring more support to remain independent in their homes and communities by providing assistance with:
Activities of daily living, such as eating, bathing, grooming and transferring
Health-related tasks
Instrumental activities of daily living, such as shopping, cooking and laundry
If you have not yet applied for MA for your child, then the first step to apply for MA under the TEFRA option is to complete an application for MA. Your child can be the only one in the household applying for health coverage. If your child is eligible for MA, you do not need to pursue MA under the TEFRA option. The services granted under TEFRA are available to all children who qualify for MA.
If your child was denied MA because your family income is too high or was found eligible for MinnesotaCare or a qualified health plan (QHP), you do not have to reapply for MA under the TEFRA option. Contact your county or tribal office for the next steps if this is the case.
When completing either application, you would answer “yes” to at least one question about disability. Examples of the questions to answer “yes” to are the following:
Is your child blind?
Does the child have a physical, menta, or emotional health condition that limits daily activities (such as bathing, dressing or chores)?
Does your child need assistance to stay in your home or help paying for care in a long term care facility?
Are you applying for a child that has a disability determination or a condition you believe is disabling, and needs additional services or supports?
Has your child been determined disabled by the Social Security Administration (SSA) or the State Medical Review Team?
Your county or tribal office will review the application and if the child is found ineligible for MA due to family income, the agency may send out a request for more information along with TEFRA information. Your county or tribal office will need to send a referral to SMRT for a disability determination and level of care determination.
SMRT will evaluate your child’s level of care and may also certify your child’s disability if the SSA has not already done so. SMRT will contact you directly to request any more information they need.
SMRT sends a certification or denial letter to your child, the authorized representative, and the county or tribal agency.
If SMRT certified your child’s disability, a county or tribal worker approves MA under the TEFRA option.
Your child may still be eligible for MA under the TEFRA option. You must tell us whether your child has other health insurance or could be covered by someone else's insurance. Sometimes we can pay the cost of the other insurance so you can keep that coverage.
