2133 TEFRA/Katie Beckett | Medicaid

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

TEFRA/Katie Beckett

Effective Date:

July 2024

Chapter:

2100

Policy Number:

2133

Previous Policy Number(s):

MT 57

Updated or Reviewed in MT:

MT-72

Requirements

Katie Beckett is a class of assistance (COA) available to children under age 18.

These individuals are determined to be in need of institutionalized care but have chosen to remain at home because they can be cared for at a lower cost. Katie Beckett allows the deeming of the income and resources of the child’s parents to be waived when determining ABD Medicaid eligibility.

Basic Considerations

To be eligible under the Katie Beckett COA, an A/R must meet the following conditions:

The A/R’s age does not extend past the month s/he turns age 18.
The A/R is chronically impaired to the extent of being a suitable candidate for institutionalized care (nursing facility, hospital or intermediate care facility for the intellectually disabled).
The A/R is financially ineligible for SSI in a private living arrangement (LA-A, B or C) due to his/her own income and/or resources or income/resources deemed from his/her parent(s).
The A/R meets the Level of Care (LOC) basic eligibility criteria.
The A/R meets all other basic and financial eligibility criteria.

Length of Stay (LOS) is not a requirement for this COA.

In some situations, a child may be eligible for either EDWP/CCSP, NOW/COMP, or Katie Beckett. The benefits of each COA should be explained to the parent(s) or other authorized representative (AREP). Also, the availability of CCSP and NOW/COMP services should be considered.

Procedures

Follow the steps below to determine ABD Medicaid eligibility under the Katie Beckett COA.

Applications

Step 1

Accept the A/R’s Medicaid application.

Additionally, for new applications, add the parents' income to the case, add Parents to the applicant group, and list the parents as the Authorized Representatives in Gateway.

Step 2

Screen for SSI financial eligibility:

Complete an SSI trial budget, deeming the income and/or resources of the child’s parent(s). Refer to Section 2508, Deeming. Allow a one third deduction to the child’s own income if it is Child Support from a non-custodial parent.
- If the child is financially eligible for SSI refer the child to SSA for an SSI determination and proceed with the Katie Beckett application.
- If the child is financially ineligible for SSI, proceed with the Katie Beckett application.

Review any reduction in the income or resources that might make the child eligible for SSI. Schedule interim reviews if changes are anticipated and terminate Katie Beckett Medicaid if the child becomes eligible for SSI.

Step 3

Give the family (or foster care worker if A/R is foster child) a packet of information regarding Katie Beckett COA. Go over forms/instructions with them so that they thoroughly understand how to complete. This packet should include:

Katie Beckett Cover Letter
Pediatric DMA-6(A) and instructions for completion
TEFRA/Katie Beckett Medical Necessity/Level of Care Statement (DMA-706)
Cost-Effectiveness Form (DMA-704)

The A/R’s family (or foster care worker), the attending physician and Medicaid Eligibility Specialist (MES) have roles in completing a DMA-6(A) on the A/R.

The A/R’s physician completes the Medical Necessity/Level of Care Statement that outlines how the child’s needs are met and the desired outcomes.
The caregiver (parent or guardian) must sign and date.
Foster Care members must have the signature of the DFCS representative.
The A/R’s physician completes the Cost-Effectiveness Form.

Refer to Appendix F – Forms for instructions in completing DMA-6(A) and the Medical Necessity/Level of Care Statement.

Step 4

When the family (foster care worker) returns the DMA-6(A), the Cost-Effectiveness Form and the Medical Necessity/Level of Care Statement check the forms to make sure that EVERY question has been addressed, even if completed with N/A (not applicable). The forms must be signed with original signatures by the physician, parent(s), foster care worker as indicated. Stamped signatures are not acceptable. The doctor’s signature date on the DMA-6(A) is valid for 90 days.

Return to the family for completion if lacking any of the requirements. Give them a reasonable time frame in which to return information.

Step 5

Have the family (foster care worker) obtain a signed psychological evaluation if any of the following is indicated on the DMA-6(A):

Section B, item number 13, has a diagnosis of either mental illness, intellectually disabled, autism, or Asperger’s syndrome

OR
Section C, item number 33, Behavioral Status has ANY of the boxes checked OTHER THAN “Cooperative” and/or “Alert”.

The psychological evaluation must be completed by a licensed professional and is required every three (3) years. Licensed professionals approved to do this testing include Developmental Pediatricians and Ph.D. Psychologists. Psychological evaluations completed by school psychologists, preschool diagnosticians, and education diagnosticians with M.Ed., Ed.S., M.A., M.S., CAS, CAGS, Psy.S, Psy.D, SSP, or Ed.D degrees are also accepted. Developmental Evaluations done by Early Interventionist with Babies Can’t Wait are accepted for children with an Individualized Family Service Plan (IFSP). The evaluation must be completed within the last 3 years of the evaluation date whether it is an initial application or review.

Give the family a reasonable time in which to return the psychological evaluation.

Step 6

When the Medical Necessity/Level of Care Statement, Form DMA-706, is received from the family (foster care worker), make sure copies of therapy notes are attached if indicated. The signature date on the Medical Necessity/Level of Care Statement is valid for 90 days.

Step 7

When the Medical Necessity/Level of Care Statement, Form DMA-706, is received from the family (foster care worker), make sure copies of Individualized Family Service Plan (IFSP) or Individualized Education Plan (IEP) are attached if indicated.

Step 8

Once the MES has received all the necessary information/forms, the MES becomes the “gatekeeper” of the material. As such, copies should be made of any data sent to Alliant Health Solutions (AHS).

Step 9

The LOC determination is obtained by mailing the following completed items to AHS.

Level-of-Care determination routing form/checklist (DMA-705)
DMA-6(A)
Medical Necessity/Level of Care Statement (DMA-706)
Psychological (if indicated)
Therapy Notes (if indicated)
Skilled Nursing Notes (if indicated)
IFSP (if indicated)
IEP (if indicated)

Send ALL items together at one time. Please check all forms and make sure they are complete. Mail packet to:

Alliant Health Solutions
Attention: TEFRA/Katie Beckett
P.O. Box 105406
Atlanta, GA 30348

If at any time the mailing address of the parents of a KB child changes during the LOC determination process please notify AHS via the TEFRA/Katie Beckett routing form/checklist (DMA 705).

Step 10

AHS reviews the information submitted and does the following:

If packet is incomplete, AHS will issue an initial denial letter which includes what items are missing.
- Letter is sent to Katie Beckett Specialized Team and family. The Family will have 30 days to return the missing information to AHS. The address for the family to mail information to is printed on the letter. If the family mistakenly sends the information to DFCS, forward immediately to AHS to the address on the letter.

If additional information is not received by the 30th day then the initial denial letter will become final.

If packet is complete, AHS makes the LOC determination.
- If LOC approval letter is received from AHS, continue with eligibility determination process, Step 15.
- If LOC is initially denied by AHS, the family and DFCS will receive an “Initial Denial of Admission” letter. Proceed to Step 11.

Step 11

If AHS denies LOC or family fails to appeal and/or provide additional clinical information within the 30 days after the LOC denial, “the initial denial becomes a final denial. If AHS denies LOC after reviewing additional information”, the eligibility worker and household will receive a Final Determination Denial of Admission. The family will have an additional 30 days in which to appeal (remove and/or provide medical information) as currently outlined in the section. When counting days, day one is the first day following the date on the letter, regardless of whether that day is a weekend or a holiday. However, if the 30th day falls on a weekend or a holiday, the next full business day is the 30th day. The address for the family to respond to is printed on the letter.

If the family mistakenly sends the information to DFCS, forward immediately to AHS to the address on the letter.

AHS will make a LOC determination and a disability determination, and the MES will proceed as follows:

If approved, continue with eligibility determination process, Step 15.

For applications, MES will deny the case for no LOC. DO NOT SUPPRESS notice. For reviews, see REVIEW in this section.

If the family challenges the LOC denial, the family will send the appeal directly to DCH’s Legal Services at:

Georgia Department of Community Health
Legal Services Section
2 Martin Luther King Jr. Drive SE East Tower
Atlanta, Georgia 30334

The appeal to DCH must be made within 30 days of the date of the LOC denial letter. When counting days, day one is the first day after the date on the letter, regardless of whether that day is a weekend or holiday. However, if the thirtieth falls on a weekend or holiday, the next full business day is the thirtieth day.

Should the family send the appeal to DFCS, forward the appeal to DCH’s Legal Services. The state office Medicaid Unit will notify the county if an appeal has been filed. There are no benefits to continue with a denied application.

An Administrative Law Judge (ALJ) conducts the hearings for both LOC hearings and hearings for other reasons. However, requests for LOC hearings are routed through DCH Legal Services, not through OSAH. Follow the OSAH procedures (Appendix B – Hearings) for any hearing requests other than LOC.

Step 12

The MES will do the following based on the outcome of the final LOC hearing:

If the ALJ upholds the LOC denial, the case remains closed. No further action is required. However, if the family wants to appeal the ALJ decision, see Step 13.
If the ALJ overturns the LOC denial and provides a letter to that affect, the MES will register the Katie Beckett case again using the original application date and complete the eligibility determination process. It is not necessary to have the family sign a new application. Proceed to Step 15 or any other step not completed.

Step 13

To appeal the ALJ decision, the family should file a written request for an agency review within 30 days of receipt of the decision to:

Department of Community Health
Commissioner Frank W. Berry
Office of the General Counsel
2 Martin Luther King Jr. Drive SE East Tower
Atlanta, Georgia 30334

A copy must also be sent to DCH Legal at the same address in Step 11, or they may fax copy to 404-657-9711.

Step 14

Determine the child’s suitability for care under a home care plan in lieu of institutionalized placement using the Cost-Effectiveness Form and the Katie Beckett Worksheet. Refer to Appendix F – Forms for the Worksheet.

Complete a Katie Beckett Worksheet as follows:

Based on the approved LOC as determined by AHS, select the Medicaid cost of the appropriate institution using DCH’s provided amounts. Refer to Appendix A1 for amounts. Base the type of institution chosen by the LOC reflected on the LOC approval letter.
Subtract the physician’s estimated monthly cost of home care on the Cost- Effectiveness Form from the monthly Medicaid billing rate of the institution.
If in-home care is more costly, deny the Katie Beckett application.
If in-home care is less costly or equal to, proceed with the Katie Beckett application.

Take into consideration in the cost comparison process any health or LTC insurance coverage. Do not use GAPP services/costs in the cost effectiveness determination. This includes skilled nursing care.

The MES should never complete the Cost-Effectiveness Form for the family. If the doctor leaves blanks on the form, it is up to the family to get it completed. Other medical entities may complete and initial the parts of the form that pertain to services they render to the A/R.

Step 15

Proceed with the eligibility determination process, completing financial and other Basic Eligibility Criteria, if not already completed.

Medicaid eligibility under the Katie Beckett COA is not held to the pay date shown on the LOC approval letter for new applications or LOC expirations. For new applications, the three months prior may be approved even if those months pre-date the pay date on the LOC letter. For LOC expirations, the LOC is approved from the end date of the previous LOC approval even if those dates pre-date the pay date on the LOC approval letter. The end date of the LOC is one year from the date that the LOC determination was completed by AHS, unless the LOC letter indicates otherwise.

Step 16

If the A/R meets all eligibility criteria, approve Medicaid in Gateway by entering all pertinent data including any retroactive months. The system will determine financial eligibility using the Medicaid Cap and issue notification letter(s). There is no patient liability for this COA.

Renewals

Complete a review of eligibility annually and document any anticipated change in resources, income or potential SSI eligibility.

At renewal if not already present in case, add the parents' income to the case, add parents to the applicant group, and list the parents as the authorized representatives on the authorized representative page.

Complete Steps 3, 4 – 9, and 14 - 16. If the DMA-6(A) indicates that a psychological evaluation is required, see Step 5 for procedures. A psychological is only valid for 3 years from the date of the evaluation. If the Care Plan indicates the A/R receives therapy, follow procedures in Step 6. If the Care Plan indicates IFSP and/or IEP, follow procedures in Step 7.

Children currently eligible for Katie Beckett but Do Not have a Disability Determination:

To ensure that a disability decision has been made on previously approved cases, when a Katie Beckett comes up for eligibility renewal and it has an approved LOC but no disability Decision, please request an updated letter from AHS to include disability.

Complete the following if the LOC is denied:

If the family receives a letter of “Initial Denial of Admission” and submits additional clinical information timely to AHS, leave case open pending “Final Determination Denial of Admission” or LOC approval.
If family receives the “Final Determination Denial of Admission” from AHS, the family has 30 days in which to appeal. The MES should close the case effective the end of the month in which the 30-day appeal time falls. DO NOT waive notice.
The state office Medicaid Unit will notify the county if the family has requested an appeal of the LOC. If the family appeals and requests that the case remains open pending the appeal or provides additional medical information to AHS, the MES should reinstate the case. Add the following text to the reinstatement notice: “Case is reopened pending the outcome of the appeal or reconsideration based on additional medical information.”
If the family appeals the denial and the LOC denial is overturned, reinstate the case, if not already reinstated.
If the family appeals the denial and the hearing upholds the LOC denial, close the case, if reinstated, and waive the notice. If the family wishes to appeal the upheld LOC denial, they should make this appeal in writing to the DCH Commissioner. See Step 13.

If the family does not appeal, the case remains closed

The end date of the LOC is two years from the date that the LOC determination was completed by AHS, unless the LOC letter indicates otherwise. Never allow the LOC to expire before a new one is obtained. Best practice is to send the Katie Beckett packet with the DMA-6(A) to the family at least a month prior to the expiration of the LOC.

Anytime the A/R becomes ineligible for Katie Beckett Medicaid, terminate the case and complete a CMD. Refer to Section 2052, Continuing Medicaid Determination.

Procedures for Child Turning Eighteen

In the month the A/R turns 18 years of age, allow the Katie Beckett COA to close for the ongoing or following month. Then register and approve the A/R under AMN De Facto COA beginning the first month the Katie Beckett COA is closed. Send a verification checklist to the A/R or AREP requesting verification of application for SSI benefits. If the A/R fails to apply for SSI, close the existing case for failure to make application for other benefits. If the A/R provides verification of application for SSI, allow the AMN De Facto COA to remain open until the month after the month the child turns 19 years of age or until the SSI application is approved. If SSA makes a determination of not disabled, close the AMN De Facto COA providing timely notice.

Eligibility must be reviewed under all Medicaid COA’s (Waivers, etc.) before closing the (AMN De Facto) COA.

Special Considerations

A disabled child may be eligible for a $30 SSI personal needs allowance from SSA if s/he meets the following criteria:

Is disabled
Received SSI benefits (limited to PNA) while in a medical treatment facility
Is ineligible for SSI solely because of deemed income or resources of the parents
Is currently eligible for Medicaid under one of the following COAs:
- Katie Beckett (Section 2133)
- EDWP/CCSP (Section 2131)
- Services under GAPP (Section 2933)

If the child meets the above criteria, refer the parent(s) to SSA to continue the SSI $30 PNA payment and Medicaid. Continue to maintain the child under the COA above unless the child no longer meets the criteria for that program.