Special Health Issues: TEFRA/Katie Beckett

Overview

Katie Beckett

TEFRA/Katie Beckett is an eligibility pathway for the Medicaid Program. It is for certain children who have long-term disabilities or complex medical needs and live at home. It allows children to be served at home by the family with additional supports, instead of in an institution. Under TEFRA/Katie Beckett, only the child’s income and resources are considered (not those of the parents).

If an individual child is eligible for DC Medicaid under TEFRA/Katie Beckett, then they can receive the same benefit package as other children enrolled in Medicaid.

Eligibility Criteria

To be eligible for DC Medicaid under TEFRA/Katie Beckett, the child must:

  • Be younger than 19 years old;
  • Have income less than 300% of Supplemental Security Income ($2,094 monthly in 2012), and resources totaling less than $2,000;
  • Have a disability that is terminal or expected to last for more than 12 months (or otherwise meet the definition of disabled under the Social Security Act);
  • Require a level of care (LOC) that is typically provided in a hospital, skilled nursing facility, or intermediate care facility (including intermediate care facilities for people with intellectual disabilities);
  • Be able to safely live at home; and
  • Not be eligible for Medicaid under a different eligibility category.

Additionally, the estimated cost of providing care in the home cannot cost Medicaid more than if the child were served in an institution.

Medicaid and Other Insurance

A child may have DC Medicaid (under TEFRA/Katie Beckett) and other health insurance. In those instances, the other insurance is billed first and then Medicaid provides “wrap-around” coverage for medically necessary services that a private insurance plan may not cover.

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The rest of this section contains information on the application process and answers to frequently asked questions.

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