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Accessing MA, TEFRA and other public support programs

What is Medical Assistance?

Medical Assistance is Minnesota’s Medicaid program that provides services to low-income senior citizens, families, children, and people with disabilities. There are three kinds of MA, based on the following:

1. Household income (if individual is under 18)
2. Personal income (if individual is over 18 and living with their parents)
3. If child/young adult has a certified disability (also known as TEFRA)

How do I apply for MA (and/or) TEFRA?

The MA application can be found through the MN Sure marketplace (listed below) or your local county office. If your child has a disability, they must be certified as disabled by the State Medical Review Team. Once certified as disabled, both the MN Sure application and supplemental application must be completed to qualify for disability services.

What is the State Medical Review Team (SMRT)?

SMRT determines if the child is disabled, and issues a disability certification. A child must have a physical, medical, mental health condition that has persisted for at least 12 months that significantly limits their ability to perform daily living tasks, work and life in the community. The certification is the first step in obtaining Medical Assistance (MA) for children with disabilities. It is based on the Blue Book criteria, published by the Social Security Administration (SSA).  Those already declared disabled by SSA, do not have to go through SMRT.

What is disability certification?

This is the basis for disabled individuals to be eligible to receive county and state benefits.  The disability must be certified by Social Security Administration (SSA) or the State Medical Review Team to qualify for disability services, using the Blue Book criteria.

What is the Blue Book?

Also known as the Disability Evaluation under Social Security, the Blue Book describes criteria for determining disability. This is used both by SSA, as well as the State Medical Review Team to certify an individual as disabled.  It includes a list of impairments for both children and adults. 

What is TEFRA?

TEFRA is a Medical Assistance (MA) program that provides services to children with disabilities, or chronic illnesses that live at home with their families and meet all the eligibility criteria (including Blue Book criteria). Children must be certified as disabled. TEFRA provides secondary insurance and might cover what your private insurance doesn’t cover (copays, deductibles, and uncovered expenses) as well as disability services.

What are disability services?

This is a menu of services provided to individuals certified as disabled.  It   includes services such as respite care, Personal Care Assistance, nursing cares and more.

What is an Individual Health Care Plan?

An Individual Health Care Plan (IHCP or IHP) provides important information regarding your child’s health considerations at home or school. This plan gives schools necessary medical information such as medication administration, solutions to potential health problems, and plans for emergency medical situations, and creates goals for your child’s health habits.

What is the process to get TEFRA?

The first steps are to fill out the MNSure application, and Supplemental Application, and gather all information related to your child’s disability, including school records, testing, assessments, medical and hospital records, etc. Contact your local county Social Service/Disability office, and request a MN Choices Assessment. The county is responsible for putting all of your information together, to send to SMRT. If the state certifies your child as disabled, then the information is sent back to the county. TEFRA will go back and pick up any unpaid medical bills, 3 months from the application date.

What is a MN Choices Assessment?

A MN Choices Assessment involves an intake worker, sent by your county  to your house, to assess your general health, degree of independence and the assistance and support you may need from others. This helps anyone with a disability or long-term care need receive the supports they need.  A report with a community support plan outlines available programs to get your needs met.

What are the income limits for TEFRA?

There are no income limits for TEFRA.

What is a cost-effective reimbursement?

The state prefers that your child has primary health insurance coverage. When you carry private insurance, and apply for TEFRA, you can request a cost effective study to see if your private insurance is cost effective per the state’s formula. If it is, the state is willing to reimburse the child’s portion of a family policy. (For example ¼ of the premium will be reimburse for a family of 4.)

What is a waiver?

Medicaid waivers are an option, when an individual’s needs cannot be met by Medicaid alone.  This helps people with disabilities live in their home or community rather than an institution. Each waiver has specific eligibility requirements and can support the health and safety of an individual with a disability or complex medical needs. Each county chooses whose needs would best be met through a waiver.

What are the different types of waivers?

• Developmental Disability Waiver (DD Waiver):
  This is a funding source for children and adults with developmental disabilities or related conditions who need the level of care provided in an Intermediate Care Facility for Persons with Developmental Disabilities (ICF/DD).

• Brain Injury Waiver (BI Waiver):
  This is a funding source for children and adults who have a traumatic or acquired brain injury who need the level of care provided in a nursing home or neurobehavioral hospital

• Community Alternative Care Waiver (CAC Waiver):
  This is a funding source for children and adults who are chronically ill and medically fragile who need the level of care provided in a hospital.

• Community Access for Disability Inclusion Waiver (CADI Waiver):
  This is a funding source for children and adults with disabilities who require the level of care provided in a nursing facility.

How do I get a waiver?

Each county has the option of how they wish to distribute waiver funds, which are limited.  Generally, if an individual’s needs cannot be met by MA alone, a waiver is considered. A waiver can be requested at the time of a   MN Choices assessment.  Some counties prefer that you receive a certification of disability first.   Depending on the type of waiver, disability certifications may come through Social Security, State Medical Review Team or your doctor. All waivers are funded through Medical Assistance (MA) Disability.  You can apply through your county or online. You can schedule a MN Choices Assessment online or through your county. A MN Choices Assessor will come to your home to evaluate whether your child qualifies for services and this will be done annually to ensure they still qualify. You will receive a written assessment summary from the county.

This chart illustrates the steps in receiving Public Health Insurance.

How can I appeal a decision made by the county regarding my waiver eligibility?

Each county has the right to determine how they choose to deliver their funds. If your needs, or your child’s needs can be met without waiver funds, getting a waiver is NOT an entitlement. There is an appeal process/form (see below) but each county has the right to prioritize its applicants, based on the highest need.

What is a PCA?

PCA stands for personal care assistant. This is a disability service provided for qualified individuals that are dependent in Activities of Daily Living (ADLs). The individual with a disability must not live in an institution. If approved for PCA hours, the PCA may assist with ADLs, health related   procedures, and behavioral issues.

What are ADLs (activities of daily living)?

ADLs include grooming, dressing, bathing, transferring, mobility, positioning, eating and toileting.  Dependence in ADLs (eg hands on assistance or constant cues to complete the task of dressing, bathing, etc.) are used to assess individual needs for PCA services and the amount of time they can receive PCA assistance.

How do I get a PCA?

To receive PCA services, a person must be enrolled with Medical Assistance (MA), MinnesotaCare expanded benefits, Alternative Care Program or a waiver program. Eligibility is determined by a PCA assessment done through your local county agency or tribe, or your health plan member services. An assessor will visit your home, to review your daily tasks and overall health. This assessment is part of the MN Choices Assessment.  After the assessment is complete, you will receive a letter that tells you how many hours of PCA care you qualify for, and a list of providers you can choose from.

What is PCA Choice vs Traditional PCA?

PCA Choice is an option that allows you to choose, hire, and manage your PCAs.  Some PCA agencies, only provide services for PCA choice. With this option, the agency only provides the background check, payroll services and some basic training.  PCAs are generally paid at a higher rate, since the agency is not responsible to advertise, and train the PCA on your needs.  If you choose to use traditional PCA services, the agency you hire will perform all of these tasks for you, and PCAs are generally paid less.

What is a Parent PCA provider?

A spouse or parent of a minor is allowed to be paid up to 40 hours a week to provide personal assistance to their child (or spouse) that qualifies for PCA services, and chooses to use funds from either a Consumer Support Grant, or Consumer Directed Community Supports.

What is a Consumer Support Grant? (CSG)

CSG is a state-funded program that provides alternative funding to help people with functional limitations purchase services to help keep them safe and in their own home. Services available for purchase include home care nursing, home-health aide, personal care assistance, special diet, music therapy, hypo therapy, special equipment, etc.  CSG is voluntary for consumers and counties but allows flexibility to a person’s specific needs, when available.  It is also the mechanism for parents or spouses to provide PCA services.

What is a Consumer Directed Community Support (CDCS)?

CDCS is a choice that individuals on waivers can make about how to spend their waiver dollars.  This provides more choice and responsibility for a person’s services and supports through directing their own needs described in their most recent developmental or long term care screening. Individuals receive a budget allowance, and can use the money to hire individuals and service providers that best meet their needs. They have full employer responsibility

Can family members be paid as a PCA to care for my child with special health care needs?

Yes. The relative would need to enroll with Minnesota Department of Human Services and complete an Individual Personal Care Assistance training which is offered online with a completion certificate. After the training is complete, the individual would then forward the certificate to their PCA agency and the recipient would elect their relative as their caregiver.