Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 20 - Division of County Operations
Rule 016.20.11-002 - Revisions to MS Policy 27000, Appendix P, and PUB-405 - TEFRA Waiver

Universal Citation: AR Admin Rules 016.20.11-002

Current through Register Vol. 49, No. 9, September, 2024

Notice of Rule Making

Pursuant to Arkansas Code 20-76-201, and Section 1916A of the Social Security Act, the Director, Division of County Operations issues proposed revisions to MS Policy 27000, Appendix P, and PUB-405, TEFRA Waiver, to not assess a premium to a family whose annual income after allowable deductions is at or below 150% of the Federal Poverty Level. Copies of the proposed change may be obtained by writing the Division of County Operations, P.O. Box 1437, Slot S-332, Little Rock, AR 72203, Attention: Office of Program Planning & Development. All comments must be submitted in writing to the address indicated above no later than _____

If yoy need this material in a different format, such as large print, contact our Americans with Disabilities Act Coordinator at 682-8920 (voice) or 682-8933 fTDD).

The Arkansas Department of Human Services is in compliance with Titles VI and VII of the Civil Rights Act and is operated, managed and delivers services without regard to religion, disability, political affiliation, veteran status, age, race, color or national origin.

Summary of Changes

Determining TEFRA Premium Amount

MS Policy }7000, Appendix P and PUB-405 have been revised to incorporate the change for determining TEFRA Premium amounts. A premium will not be assessed if the family's annual income after allowable deductions is at or below 150% of the Federal Poverty Level.

MS - TEFRA WAIVER/HOME CARE FOR CHILDREN TEFRA WAIVER

27000 TEFRA Waiver/Home Care for Children

TEFRA Waiver is a Section 1115(a) demonstration waiver which 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 receive the full range of Medicaid benefits and services. There is no cap on the number of children covered by the program.

Cost sharing measures are based on household size and total annual income of the custodial parent(s) as reflected on the most recently filed IRS Federal Tax Return. A family's total annual out-of-pocket cost sharing cannot exceed five percent of the family's gross income. There are no co-payments charged for services to TEFRA Children.

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.

27005 Eligibility Requirements07-01-11

The following eligibility requirements must be met for a child to be eligible for TEFRA Waiver:

1. Age: The child must be 18 years of age or younger. Eligibility will end on the child's 1ST birthday.

2. Disability: The child must be disabled according to the SSI definition of disability. If disability has not been established by SSA, it must be determined by MRT ([MS 33221).

3. Citizenship or Alien Status: The child must be a U.S. citizen or a qualified alien ([MS 3310 #31 and [MS 3324]).

4. Residency: The child must be an Arkansas resident (MS 22001).

5. Social Security Enumeration: The child must meet the Social Security Enumeration requirements shown at MS 13901.

6. Income: The child's gross countable income must be less than the current Long Term Care (LTC) income limit, (Re: SSI Chart at [Appendix SI). In-Kind Support and Maintenance is not considered income in TEFRA cases. SSI exclusions are not allowed. Parental income is not considered in the eligibility determination, but is considered for the purpose of calculating the monthly premium (Re: l"MS 270101).

7. Resources: The child's countable resources cannot exceed $2,000.00. The parents' resources are not considered. No period of ineligibility will be imposed for transfers made without compensation.

8. MedJcal Necessity: The child must either meet the medical necessity requirement for institutional placement in an acute care facility, a skilled nursing facility, an ICF/MR facility or Alternative Home placement, or be at risk for future institutional placement. The determination of medical necessity will also be based on services that improve, maintain or prevent regression of the child's health status and will be based on the child's medical, health and family situation.

9. Appropriateness of Care: Medical services must be available to provide care to the child in the home, and it must be appropriate to provide such care outside an institution.

10. Cost Effectiveness: The estimated cost of care for the child in the home cannot exceed the estimated cost of care for the child in an institution.

11 . Child Support Enforcement Referral: A TEFRA child is eligible for free services through OCSE. If the child's custodial parent receives Medicaid in a category other than Pregnant Women or Family Planning, cooperation with OCSE is mandatory. If the custodial parent does not receive Medicaid, referral to and cooperation with OCSE is strictly voluntary.

12. Payment of Premiums: Some TEFRA Waiver households will be required to pay a sliding scale monthly premium based on the income of the custodial parent(s) beginning with families estimated to be earning in excess of $25,000 annually and whose income exceeds 150 percent of the Federal poverty level (FPL). The monthly premium will only be assessed if the family income is in excess of 150 percent of the FPL (Re. [MS 270201).

13. Dropped Health Insurance Coverage: A child can receive TEFRA Waiver services and retain health insurance coverage. For applicants, if primary comprehensive health insurance is voluntarily dropped for the Waiver child in the six months prior to application, the child will be ineligible for TEFRA benefits for a period of six (6) months from the date the insurance is dropped. Primary comprehensive health insurance is insurance that covers both physician and hospital charges. For recipients, if it is found at the yearly reevaluation that health insurance coverage was voluntarily dropped after the case was approved, the case will be closed for six (6) months beginning with the month following the month of discovery.

The six-month period of ineligibility will apply unless one of the following conditions is met:

[GREATER THAN] The health insurance is a non-group or non-employer sponsored plan.

[GREATER THAN] The health insurance was lost through termination of employment for any reason, including voluntarily quitting.

[GREATER THAN] 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.

27010 Determining Monthly Premiums07-01-11

No premium will be assessed for those waiver recipients with an annual gross family income of less than $25,000. The amount of the premium will be determined based on the number of family members residing in the home and the custodial parent(s) total gross 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 1040A) less the following deductions:

[GREATER THAN] 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.

[GREATER THAN] 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:

$65,417.48

- 1,800.00 ($600 X 3)

- 9.463.25

$54,154.23 [LESS THAN] Income used to determine TEFRA premium

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 PI 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.

See [Appendix PI 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, number of family members residing in the home, 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.

27015 Adjustment of Premiums

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 or change in the number of family members residing in the home. 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 or the number of family members residing in the home. 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.

27020 Payment of Premiums

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.

27000 TEFRA Waiver/Home Care for Children01-01-03

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 shajring 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.

27005 Eligibility Requirements07-01-06

The following eligibility requirements must be met for a child to be eligible for TEFRA Waiver:

1) Age: The child must be 18 years of age or younger. Eligibility will end on the child's 19th birthday.

2) Disability: The child must be disabled according to the SSI definition of disability. If disability has not been established by SSA, it must be determined by MRT (MS 3322).

*3) Citizenship or Alien Status: The child must be a U.S. citizen or a qualified alien (MS 6705 and MS 6710-6783).

4) Residency: The child must be an Arkansas resident (MS 2200).

5) Social Security Enumeration: The child must meet the Social Security Enumeration requirements shown at MS 1390.

6) Income: The child's gross countable income must be less than the current Long Term Care (LTC) income limit. (Re: SSI Chart at Appendix S). In-Kind Support and Maintenance is not considered income in TEFRA cases. SSI exclusions are not allowed. Parental income is not considered in the eligibility determination, but is considered for the purpose of calculating the monthly premium (Re: MS 27010).

7) Resources: The child's countable resources cannot exceed $2,000.00. The parents' resources are not considered. No period of ineligibility will be imposed for transfers made without compensation.

8) Medical Necessity: The child must either meet the medical necessity requirement for institutional placement in an acute care facility, a skilled nursing facility, an ICF/MR facility or Alternative Home placement, or be at risk for future institutional placement. The determination of medical necessity will also be based on services that improve, maintain or prevent regression of the child's health status and will be based on the child's medical, health and family situation.

9) Appropriateness of Care: Medical services must be available to provide care to the child in the home, and it must be appropriate to provide such care outside an institution.

10) Cost Effectiveness: The estimated cost of care for the child in the home cannot exceed the estimated cost of care for the child in an institution.

11) Child Support Enforcement Referral: A TEFRA child is eligible for free services through OCSE. If the child's custodial parent receives Medicaid in a category other than Pregnant Women or Family Planning, cooperation with OCSE is mandatory. If the custodial parent does not receive Medicaid, referral to and cooperation with OCSE is strictly voluntary.

12) Payment of Premiums: TEFRA Waiver households with annual income over $25,000 will be required to pay monthly premiums. (Re. MS 27020).

13) Dropped Health Insurance Coverage: A child can receive TEFRA Waiver services and retain health insurance coverage. For applicants, if primary comprehensive health insurance is voluntarily dropped for the Waiver child in the six months prior to application, the child will be ineligible for TEFRA benefits for a period of six (6) months from the date the insurance is dropped. Primary comprehensive health insurance is insurance that covers both physician and hospital charges. For recipients, if it is found at the yearly reevaluation that health insurance coverage was voluntarily dropped after the case was approved, the case will be closed for six (6) months beginning with the month following the month of discovery.

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.

27010 Determining Monthly Premiums

All waiver recipients with annual gross family income over $25,000 will pay a monthly premium. The amount of the premium will be determined based on the custodial parent($) 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 1040A) 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:

$65,417.48

- 1,800.00 ($600X3)

- 9,463.25 $54,154.23

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.

27015 Adjustment of Premiums

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.

27020 Payment of Premiums

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.

APPENDIX P TEFRA

Premium Schedule How to determine TEFRA Premium Range

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APPENDIX P TEFRA Premium Schedule

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