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 receive services at home 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). For more information on TEFRA/Katie Beckett, please read the TEFRA/Katie Becket Fact Sheet and Frequently Asked Questions document.
Who is Eligible?
To be eligible for DC Medicaid under TEFRA/Katie Beckett, the child must:
- Be a resident of the District of Columbia;
- Be a US citizen or have eligible immigration status;
- Be eighteen (18) years old or younger;
- Have income less than 300% of Supplemental Security Income (SSI) and resources totaling less than $4000.
- Have a disability that is terminal or expected to last for more than (twelve) 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.
TEFRA/Katie Beckett Application Process & Required Documentation
Step 1: Submit the following documents to ESA to determine Medicaid Eligibility:
- Combined Application for Medical Assistance, Food Stamps, Cash Assistance; and
- Proof of citizenship, identity, and child and family income and resources.
Step 2: Submit Level Of Care Determination documents* to the Division of Children’s Health Services at the Department of Health Care Finance (DHCF):
- The Pediatric Level of Care Determination Form;
- TEFRA/Katie Beckett Care Plan form; and
- Supporting documents, such as the Letter of Medical Necessity, the Individualized Education Program /Individualized Family Service Plan, therapy assessments, including diagnostic reports.
*These documents do not have to be submitted with the initial Medical Assistance application, but may be requested if your family income is higher than 319% of the federal poverty limit (FPL).