Act 421 Children's Medicaid Option (Act 421-CMO/TEFRA)
Act 421 of the 2019 Regular Legislative Session tasked the Louisiana Department of Health with starting a program that lets certain children with disabilities receive Medicaid coverage, even if their parents earn too much money to qualify for Medicaid. Disabled children living at home with their family that apply for Act 421-CMO must meet an institutional level of care for an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), Nursing Facility or Hospital to be considered for this program.
Act 421 created what is known as a TEFRA option in Medicaid. TEFRA refers to the Tax Equity and Fiscal Responsibility Act of 1982, which is a United States federal law that can help families with children younger than 19 years old who have a disability receive care in their homes rather than an institution. TEFRA programs are sometimes referred to as the Katie Beckett program or the Katie Beckett waiver in other states. In Louisiana, the program is Act 421 Children’s Medicaid Option (Act 421-CMO).
Louisiana Medicaid received approval from CMS to implement the program as a State Plan Amendment. The program became effective January 1, 2022.
In order to be eligible for the Act 421-CMO option, a child must meet all of the following eligibility criteria:
- Be a Louisiana resident.
- Be a United States citizen or qualified non-citizen.
- Under the age of 19 (not to exceed the age of 18).
- Has a disability that is recognized under the definition of disability utilized in the Supplemental Security Income program of the Social Security Administration, regardless of whether the child is eligible to receive benefits under that program.
- Excluding the assets (resources) of parents, the child does not have total assets (resources) exceeding $2,000 in value.
- Excluding the income of parents, the child’s income is less than three (3) times the Federal Benefit Rate (FBR), referred to as the individual Special Income Limit (SIL).
- The child meets an institutional level of care provided in a hospital, skilled nursing facility, or intermediate care facility (ICF).
- Care provided safely at home for less than the cost of institutional care.
Steps to Enrolling in Act 421-CMO
There are four (4) general steps to enrolling in the Act 421-CMO program. In order to begin the enrollment process, complete a Medicaid application and submit verification documents. Coverage for Act 421-CMO cannot begin prior to January 1, 2022, which is the date the program, went into effect. You can view the ACT 421 CMO/TEFRA Application Process here.
Step 1. Completing a Medicaid Application
There are four (4) ways to apply for Medicaid – online, by mail, in person or by phone. Choose the method that works best for you.
- Apply online.
- To apply by phone, call 1-888-342-6207.
- To apply in person, locate the nearest application center here or Medicaid Regional office here.
- If applying by mail, download Medicaid application. Completed application can be faxed to 1-877-523-2987 or mailed to:
Medicaid Application Office
P O Box 91278
Baton Rouge, LA 70821-9893
IMPORTANT: You must select a Health plan at this step in the process. If you do not choose a health plan, a plan is randomly assigned. For more information on selecting a health plan visit: https://www.myplan.healthy.la.gov.
When applying online, you must place a check in the box next to the applicant that has a disability on the Additional Personal Details screen:
After selecting which applicant has a disability, the next screen asks for additional disability information. Choose Disabled from the drop down box:
When using a paper application to apply, the disability question (as shown in question 10 below), needs to be answered ‘yes’ to be routed for Act 421-CMO processing:
Applicants determined ineligible for other Medicaid or CHIP programs that meet all other criteria for Act 421-CMO continue to Step 2 of the enrollment process
Step 2. Level of Care Assessment at your Human Services District/Authority
Your Human Services District needs to complete an assessment to determine if the applicant meets the level of care requirement. You will receive a level of care packet, which contains documents to complete and return to LDH. All forms must be filled out completely, supporting documentation provided (where indicated) and returned to LDH timely.
Families will receive a packet to complete and return to Medicaid. The forms that you receive are dependent on which level of care pathway is deemed appropriate for your child. Your packet may contain these documents:
- Act 421-CMO cover letter with instructions on how to complete forms;
- Authorization to Release or Obtain Health Information form (HIPAA);
- Child’s Medical and Social Information form (included for the MEDT disability determination);
- 90-L Request for Medical Eligibility Determination form (and 90-L Physician Instructions); or a
- Health Records Request Form.
The Human Services District completes the assessment by reviewing information and forms provided by the applicant so it is important to follow the instructions in the level of care packet when completing the forms.
Submit the completed level of care packet to Medicaid to upload into the eligibility system via:
- Fax to: 1-225-389-8019
- Email to: LTCProcessing@la.gov
- Mail to: Medicaid Application Office; 6069 1-49 Service Road, Suite B, Opelousas, LA 70570.
- Upload the documents directly to your Medicaid account using the self-service portal. The instructions on how to upload documents to your account is located here.
Applicants that meet the level of care requirement continue to Step 3 of the enrollment process.
Step 3. Disability Determination
Applicants must meet the definition of disability as set forth by the Social Security Administration. Medicaid will request a disability decision from the Medical Eligibility Determination Team (MEDT) for applicants that do not have a disability determination with the Social Security Administration Office. MEDT may need additional documentation in order to reach a decision on the disability determination.
If you would like assistance in gathering the necessary medical records, you can sign an Authorization to Release or Obtain Health Information Form (HIPAA 202L) to obtain these records directly from the providers (physicians, home health, social service, etc.) that is in the level of care packet. This form is used to assist you in obtaining medical records needed to determine if your child meets the level of care and disability requirement for the Act 421-CMO program.
Applicants that meet the disability requirement continue to Step 4.
Step 4. Enrollment/Service Coverage through a Healthy Louisiana plan
Applicants meeting the medical and financial requirements will receive Medicaid coverage through a Healthy Louisiana plan. When completing a Medicaid application, you can choose a Healthy Louisiana health and dental plan. If you have not selected a health plan, enrollment in a health plan is automatic upon enrollment in Medicaid. The family will have 90 days from date of enrollment to change plans when automatic enrollment occurs.
Louisiana Health Insurance Premium Program (LaHIPP)
If your child is enrolled in the Act 421-CMO (TEFRA) program, LaHIPP may pay for your individual insurance plan or your employer-sponsored insurance, subject to an annual review for cost-effectiveness.
You can apply for LaHIPP here. Download the application and submit one of three ways:
- Email: La.HIPP@la.gov
- Fax: 1-855-618-5486
- Mail: LDH ATTN: LaHIPP P.O. Box 91030 Baton Rouge, LA 70821-0930
IMPORTANT: If you are approved for LaHIPP, your child will be disenrolled from the Healthy Louisiana plan (MCO) for physical health services, but will remain enrolled for behavioral health and NEMT (Non-emergency medical transportation) services. Physical health services will be covered by fee-for-service (also known as traditional Medicaid).
This may affect whether your provider accepts your Medicaid coverage. Before enrolling in LaHIPP, you can use the “Find a Provider” tool to see if your child’s doctor will accept Medicaid with LaHIPP. The tool can be found here: https://www.lamedicaid.com/apps/provider_demographics/provider_map.aspx.
Please see the Act 421 FAQs for more information on LaHIPP.
For more information, visit the LaHIPP web site.