TEFRA Medicaid
What is TEFRA?
The Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) is a Medicaid program designed to help children under 19 years old with costs related to their disabilities. This covers significant medical, developmental or psychiatric needs. Although they may be deemed "disabled" or have high medical costs, not all children qualify for this program.
​
Even if a child has insurance coverage through their parents, the co-pays, deductibles, and policy limitations (especially for therapies!) add up. TEFRA can supplement other insurance or provide stand-alone coverage to help with these costs.
​
Who Qualifies?
All TEFRA programs have the same eligibility criteria:
​
1. Children must have a medical, developmental, or psychiatric condition meeting Social Service Administration definition of disability. However, diagnosis alone is not the only criteria.
​
2. The child must also need a high level of care that would require placement in a hospital, nursing facility, or intermediate care facility* -- but can have their needs met in the community with parental help and access to medical care and services instead.
​
3. The child must live at home.
​
4. Qualified children are eligible until 19 years old.
​
In Alaska, as long as children meet the level of care criteria, parental income and resources are not counted. There is no waiting list for Alaskan TEFRA Medicaid, although there may be wait time involved with application, assessment, and approval to be completed.
​
* Special Note: "Level of care criteria" mentions hospital, nursing facility or intermediate care facility, or "institutional level of care." This is scary terminology; however, the point of this program is to make care affordable to families so the child can live at home. Please see Katie Beckett's story below to see what life was like for children with complex needs prior to TEFRA availability.
​
​
How We Can Help
We have a unique blend of personal and professional experience which gives us an awareness of how important TEFRA can be. We will help guide clients through the initial process, complete all necessary paperwork, track timelines and due dates, and gather medical documentation needed to establish eligibility.
​
Once eligibility is established, Pathfinder Care Coordination helps maintain TEFRA benefits each year during renewal by helping families comply with due date requirements and gather the necessary paperwork and documentation to continue eligibility. We can also help identify other resources as needed.
​
Need help knowing where to begin?
Feel free to contact us and we can provide a TEFRA screening and help you through this process (there is no fee to children or families for our services.)
​
Statement Regarding Qualifying and Assessment:
The services we offer are based upon diagnostic criteria, and we must follow federal and state regulations. We will gather information based on the information an individual and their family/guardians provide to us. If we feel you won't qualify for services, we may suggest alternative services in the community.
​
​If we feel a child meets the level of care for TEFRA application, we partner with our clients to gather all required documentation. We cannot guarantee whether services will be approved. Children must qualify annually to remain in the programs we serve. We do everything within our power to ensure that the process is as smooth and predictable as possible.
Meet Katie Beckett
Katie Beckett was a little girl who lived her first three years in the hospital. Despite having two working parents and insurance, insurance would not cover the home nursing services and therapies she required to live at home, even though they were cheaper than hospital care. And if she left the hospital, she would no longer be eligible for Medicaid, yet her parents could not afford to pay for the services to keep her at home.
President Reagan thought this was bad for families and wasteful spending of tax dollars to have families such as Katie's in this position. So he granted an exception that allowed Katie to move home and still receive Medicaid coverage, including private duty nursing. This exception was codified in the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982.
​
TEFRA allows financial qualification based on the child's assets only, provided the child meets all program medical and diagnostic requirements.
​
Katie Beckett passed away at the age of 34. Her struggle and that of her parents allowed literally hundreds of thousands of children with disabilities and fragile medical conditions to be supported at home rather than in a hospital or nursing facility.
