Medical Assistance under the TEFRA option for children with disabilities

To qualify for MA under the TEFRA option, a child must meet all the following requirements:

• Be otherwise ineligible for MA when parents’ income is counted
• Be under age 19 
• Live with at least one biological, adoptive or stepparent 
• Be certified disabled by the Social Security Administration (SSA) or the State Medical Review Team (SMRT)
• Need a level of care to stay at home that is similar to the level of care provided in a hospital, nursing home or intermediate care facility for people with developmental disabilities (SMRT makes the level-of-care determination).

The TEFRA option helps children with disabilities get Medical Assistance (MA) coverage by only counting the child’s income, not the whole family’s income.

Under TEFRA:

• The child’s income must be below the limit for people with disabilities to qualify for MA. See the Income and Asset Guidelines (DHS-3461A) (PDF).
• If the child’s income is higher than this limit, the child may still qualify by meeting a spenddown. A spenddown is like a deductible for medical expenses. See information about spenddowns in What is a Spenddown (DHS-3017-ENG) (PDF).

If your child qualifies for MA under the TEFRA option, the child will receive the same coverage as children enrolled in MA. This includes doctor’s visits, prescriptions and hospital stays. In addition, it can cover Community First Services and Supports (CFSS) (DHS-8477A-ENG) (PDF) which is a Minnesota health care program that allows flexible options for those requiring more support to remain independent in their homes and communities by providing assistance with:

• Activities of daily living, such as eating, bathing, grooming and transferring
• Health-related tasks 
• Instrumental activities of daily living, such as shopping, cooking and laundry 

Children on MA under the TEFRA option are not enrolled in managed care plans. Their MA coverage is provided on a fee for service basis. See Minnesota Health Care Programs Summary of Coverage, Cost Sharing and Limits (DHS-3860) (PDF) for a summary of services covered by MA.

No. Children do not have an asset limit for MA. This includes children eligible for MA under the TEFRA option.

Children eligible for MA, including MA under the TEFRA option, do not have copays or deductibles.

If you applied for health care coverage online through MNsure or by submitting an Application for Health Coverage and Help Paying Costs (DHS-6696) (PDF) and your child was denied MA due to income above the MA limit, you do not have to reapply for MA under the TEFRA option. Contact your county or tribal office for the next steps if this is the case. 

If you have not yet applied for MA for your child, then the first step to apply for MA under the TEFRA option is to complete an application for MA. Your child can be the only one in the household applying for health coverage. If your child is  eligible for MA, you do not need to pursue MA under the TEFRA option. The services granted under TEFRA are available to all children who qualify for MA.

If your child was denied MA because your family income is too high or was found eligible for MinnesotaCare or a qualified health plan (QHP), you do not have to reapply for MA under the TEFRA option. Contact your county or tribal office for the next steps if this is the case.

You can apply in either of these ways:

• Apply online through MNsure, Minnesota's health insurance marketplace. Here are some tips for completing the MNsure online application. 
• Fill out and return the MNsure Application for Health Coverage and Help Paying Costs (DHS-6696) (PDF) to your county or tribal office.

If you have already applied in the past, contact your county or tribal office and report the changes to your case.

When completing either application, you would answer “yes” to at least one question about disability. Examples of the questions to answer “yes” to are the following:

• Is your child blind?
• Does the child have a physical, menta, or emotional health condition that limits daily activities (such as bathing, dressing or chores)?
• Does your child need assistance to stay in your home or help paying for care in a long term care facility?
• Are you applying for a child that has a disability determination or a condition you believe is disabling, and needs additional services or supports?
• Has your child been determined disabled by the Social Security Administration (SSA) or the State Medical Review Team?

Your county or tribal office will review the application and if the child is found ineligible for MA due to family income, the agency may send out a request for more information along with TEFRA information. Your county or tribal office will need to send a referral to SMRT for a disability determination and level of care determination.

Once the county or tribal agency has referred the case to the DHS State Medical Review Review Team (SMRT), the following will happen:

• SMRT will evaluate your child’s level of care and may also certify your child’s disability if the SSA has not already done so. SMRT will contact you directly to request any more information they need. 
• SMRT sends a certification or denial letter to your child, the authorized representative, and the county or tribal agency.
• If SMRT certified your child’s disability, a county or tribal worker approves MA under the TEFRA option.

After your child is approved, coverage may:

• Go back to the first day of the month that we got your application.
• Go back up to three months before the month we got your application, if you request it.

Call your county or tribal office if you have questions about when coverage can start.

Your child may still be eligible for MA under the TEFRA option. You must tell us whether your child has other health insurance or could be covered by someone else's insurance. Sometimes we can pay the cost of the other insurance so you can keep that coverage.

• MNsure if you have questions about how to apply online
• County and tribal offices if you have questions about eligibility, or you are applying for Medical Assistance using a paper application
• DHS Health Care Consumer Support (HCCS) if you are not sure who to call                                                      
• TTY: Use your preferred relay service

• Disability Hub MN™ at 866-333-2466
• TEFRA Information (DHS-7960) (PDF)