The Arc Guide to Medical Assistance – TEFRA

The Medical Assistance-TEFRA (Tax Equity and Fiscal Responsibility Act) program provides Medical Assistance (MA) benefits for children with disabilities who do not otherwise qualify for MA due to their parents’ income being above MA program limits. MA-TEFRA funds disability programs, services and therapies that private insurance often does not cover or only partially covers.

The child’s eligibility for MA-TEFRA is based on a “certified disability” and additional requirements listed below.

Eligibility requirements

Live with at least one parent
Under age 19
Certified disabled by the State Medical Review Team (SMRT) or the Social Security Administration (SSA)
Require a level of care to live at home that is comparable to that provided in a hospital, nursing home or group home for individuals with disabilities
The costs for the child to remain at home are less than those at a hospital, nursing home or group home

How to apply

Apply online at www.mnsure.org (preferred) or by paper using the “MNsure Application for Health Coverage and Help Paying Costs (DHS 6696).”

List the child/ren as the only household member/s applying
Answer yes to the disability question for the child (“Does anyone applying have a physical or mental health condition that limits the ability to work or perform activities of daily living?”)
Once online application is submitted, child will be “denied” for any programs OR eligible for a Qualified Health Plan (commercial health plan sold through MNsure’s website) due to parental income and household size
Parents must complete and submit the “Supplement to the MNsure Application (DHS 6696A)” to their county of residence in order to move the child’s MA-TEFRA application forward

Even though what is described above is the state’s policy on how to apply, counties may not want families to apply through MNsure and may ask that they use the Application for Certain Populations instead. We recommend families contact their county financial unit to ask how they want them to apply for MA-TEFRA. Families can also contact a MNsure Navigator.

Determination of disability by SMRT: A county financial worker reviews the initial application and refers the case to SMRT once the worker determines the child’s initial eligibility for the program. Parents receive a SMRT welcome letter in the mail, meaning the case is at the State. The SMRT contacts parents by phone or mail when a SMRT case manager is assigned and the case is being reviewed. Parents submit disability documents directly to the State. Please refer to the Arc Guide to State Medical Review Team for more detailed information, including the list of required documentation for the SMRT process.

Once all disability documentation is received, the SMRT case manager:

Reviews medical, psychological and school records to determine if the disability meets SSA’s disability criteria
Reviews the records to determine the level of care the child needs
Approves (“certifies as disabled”) or does not certify the child as disabled
Sends the county and parents an approval or denial notice

Benefits through MA-TEFRA

Refer to “Minnesota Health Care Programs Summary of Coverage, Cost Sharing and Limits (DHS 3860)” for a complete listing of benefits and services covered by MA.

Parental Fees

As of July 1st, 2023, there is no longer a Parental Fee for MA TEFRA. Any debt incurred through June 30th, 2023 is still owed. Questions about past due payments can be directed to the Parental Fees Unit at (651) 431-3806.

Access to private health insurance

Parents must report if the child has other health coverage or could be covered under someone else’s insurance when first applying for and renewing the child’s MA-TEFRA coverage. If the child’s private insurance enrollment changes, the parent must report the change to their county financial unit.

MA-TEFRA may cover the child’s portion of the cost of the private insurance coverage if it is determined to be “cost effective” by the county agency. (See the Arc Guide to Cost Effective Health Insurance.) Access to or enrollment in private health insurance is not a barrier to eligibility for MA-TEFRA.

For further information or advocacy services, contact The Arc Minnesota at 952-920-0855 or toll-free at 833.450.1494 or visit www.arcminnesota.org. (Please note: This document is not legal advice, and should not be construed as such. Thus, no information herein should replace the sound advice of an attorney.)

June 2023