Act 421 Children's Medicaid Option (CMO)/TEFRA

 
 

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Phone:  1-800-230-0690

E-mail:  421-CMO@la.gov

 

 
 

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Act 421 of the 2019 Regular Legislative Session authorized the Louisiana Department of Health to create a TEFRA program that allows certain children who have a disability to receive Medicaid coverage, even if their parents earn too much money to qualify for Medicaid. Children with disabilities 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.

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:

  • is a Louisiana resident;
  • is a United States citizen or qualified non-citizen;
  • is 18 years of age or younger (under 19 years of age);
  • qualifies as a disabled individual under section 1614(a) of the Social Security Act;
  • has countable resources that are equal to or less than the resource limits for the Supplemental Security Income (SSI) program;
  • has income equal to or less than the special income limit (SIL) for long-term care services (nursing facility ICF/IID, and home and community-based services waiver programs, which is three (3) times the Federal Benefit Rate (FBR);
  • must meet a level of care, assessed on an annual basis, provided in an intermediate care facility for individuals with intellectual disabilities (ICF/IID), a nursing facility, or a hospital; and
  • care needs are being safely met at home at a lower cost than the cost of services provided in an institutional setting.

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. 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. 

  1. Apply online.
  2. To apply by phone, call 1-888-342-6207.
  3. To apply in person, locate the nearest application center here or Medicaid Regional office here.
  4. 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:

1. Place a check in the box next to the applicant that has a disability on the Additional Personal Details screen:

2. Select which applicant has a disability, and choose Disabled from the drop down box:

 

 

When using a paper application to apply, the disability question (as shown in question 12 below), needs to be answered ‘yes’ to be routed for Act 421-CMO processing:

 

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 timelyFailure to provide this information will result in rejection of your application for the Act 421 program.

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:

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: LALTC.processingcenter@la.gov
  • Mail to: Medicaid Application Office; 6069 1-49 Service Road, Suite B, Opelousas, LA 70570.

Or

  • Online through 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.

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, also known as a managed care organization (MCO).  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 if you are determined eligible.  

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/provider 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.

 

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