Applications

Step 1 Accept the A/R’s Medicaid application. Additionally, for new applications, add the parents' income to the case, add parents to the Applicant Group, and list the parents as the Authorized Representatives in Gateway. Step 2 Screen for SSI financial eligibility: Complete an SSI trial budget, deeming the income, resources or both of the child’s parent(s). Refer to Section 2508 - Parent to Child Deeming . Allow a one-third deduction to the child’s own income if it is Child Support from a non-custodial parent. If the child is financially eligible for SSI, refer the child to SSA for an SSI determination and proceed with the Katie Beckett application. If the child is financially ineligible for SSI, proceed with the Katie Beckett application. Review any reduction in the income or resources that might make the child eligible for SSI. Schedule interim reviews if changes are anticipated and terminate Katie Beckett Medicaid if the child becomes eligible for SSI. Step 3 Give the family or caregiver (or foster care worker if A/R is foster child) a packet of information regarding Katie Beckett COA. Go over forms/instructions with them so that they thoroughly understand how to complete. This packet should include: Form DMA 6A - Physician’s Recommendation for Pediatric Care and instructions for completion Form DMA 706 - TEFRA/Katie Beckett Medical Necessity/Level of Care Statement Form DMA 704 - TEFRA/Katie Beckett Cost-Effectiveness Form The A/R’s family or caregiver (or foster care worker), the attending physician and caseworker have roles in completing a Form DMA 6A - Physician’s Recommendation for Pediatric Care on the A/R. The A/R’s physician and primary caregiver completes the Form DMA 706 - TEFRA/Katie Beckett Medical Necessity/Level of Care Statement that outlines how the child’s needs are met and the desired outcomes. The caregiver (parent or guardian) must sign and date. Foster Care members must have the signature of the DFCS representative. The A/R’s physician completes the Form DMA 704 - TEFRA/Katie Beckett Cost-Effectiveness Form . Step 4 When the family or caregiver (foster care worker) returns the Form DMA 6A - Physician’s Recommendation for Pediatric Care, Form DMA 704 - TEFRA/Katie Beckett Cost-Effectiveness Form and the Form DMA 706 - TEFRA/Kaite Beckett Medical Necessity/Level of Care Statement check the forms to make sure that EVERY question has been addressed, even if completed with N/A (not applicable). The forms must be signed with original signatures by the physician, parent(s) or caregiver(s), and foster care worker as indicated. Stamped signatures are not acceptable. The doctor’s signature date on the Form DMA 6A - Physician’s Recommendation for Pediatric Care is valid for 90 days. Return to the family or caregiver for completion if lacking any of the requirements. Give them a reasonable time frame in which to return information. Step 5 Have the family or caregiver (foster care worker) obtain a signed psychological (6-19 years) or developmental (0 to 5 years) evaluation if any of the following is indicated on the Form DMA 6A - Physician’s Recommendation for Pediatric Care: Section B, item number 13, has a diagnosis of either mental illness, intellectually disabled, autism, or Asperger’s syndrome OR Section C, item number 33, Behavioral Status has ANY of the boxes checked OTHER THAN “Cooperative”, “Alert” or both. The psychological evaluation must be completed by a licensed professional and is required every three (3) years. Licensed professionals approved to do this testing include Developmental Pediatricians and Ph.D. Psychologists. Psychological evaluations completed by school psychologists, preschool diagnosticians, and education diagnosticians with M.Ed., Ed.S., M.A., M.S., CAS, CAGS, Psy.S, Psy.D, SSP, or Ed.D degrees are also accepted. Developmental Evaluations done by Early Interventionist with Babies Can’t Wait are accepted for children with an Individualized Family Service Plan (IFSP). The evaluation must be completed within the last 3 years of the evaluation date whether it is an initial application or review. Give the family or caregiver a reasonable time in which to return the psychological evaluation. Step 6 When the Form DMA 706 - TEFRA/Katie Beckett Medical Necessity/Level of Care Statement is received from the family or caregiver (foster care worker), make sure copies of therapy notes are attached if indicated. The signature date on the Form DMA 706 - TEFRA/Katie Beckett Medical Necessity/Level of Care Statement is valid for 90 days. Step 7 When the Form DMA 706 - TEFRA/Katie Beckett Medical Necessity/Level of Care Statement is received from the family or caregiver (foster care worker), make sure copies of Individualized Family Service Plan (IFSP) or Individualized Education Plan (IEP) are attached if indicated. Step 8 Once the caseworker has received all the necessary information or forms, the caseworker becomes the “gatekeeper” of the material. As such, copies should be made of any data sent to Alliant Health Solutions (AHS). Step 9 The LOC determination is obtained by submitting the following completed items to AHS. Form DMA 6A - Physician’s Recommendation for Pediatric Care Form DMA 705 - TEFRA/Katie Beckett LOC Determination Routing Form Form DMA 706 - TEFRA/Katie Beckett Medical Necessity/Level of Care Statement Psychological (if indicated) Therapy Notes (if indicated) Skilled Nursing Notes (if indicated) IFSP (if indicated) IEP (if indicated) Send ALL items together at one time. Please check all forms and make sure they are complete. Submit packet to: Alliant Health Solutions Attention: TEFRA/Katie Beckett P.O. Box 105406 Atlanta, GA 30348 If at any time the mailing address of the parents of a KB child changes during the LOC determination process please notify AHS via the Form DMA 705 - TEFRA/Katie Beckett LOC Determination Routing Form . Step 10 AHS reviews the information submitted and does the following: If packet is incomplete , AHS will issue an initial denial letter which includes what items are missing. The letter is sent to Katie Beckett Specialized Team and family or caregiver. The family or caregiver will have 30 days to return the missing information to AHS. The address for the family or caregiver to submit information to is printed on the letter. If the family or caregiver mistakenly sends the information to DFCS, forward immediately to AHS to the address on the letter. If additional information is not received by the 30th day then the initial denial letter will become final. If packet is complete , AHS makes the LOC determination. If LOC approval letter is received from AHS, continue with eligibility determination process, Step 15. If LOC is initially denied by AHS, the family or caregiver and DFCS will receive an “Initial Denial of Admission” letter. Proceed to Step 11. Step 11 If AHS denies LOC or family or caregiver fails to appeal, provide additional clinical information or both within the 30 days after the LOC denial, “the initial denial becomes a final denial. If AHS denies LOC after reviewing additional information”, the caseworker and household will receive a Final Determination Denial of Admission. The family or caregiver will have an additional 30 days in which to appeal (remove, provide medical information or both) as currently outlined in the section. When counting days, day one is the first day following the date on the letter, regardless of whether that day is a weekend or a holiday. However, if the 30th day falls on a weekend or a holiday, the next full business day is the 30th day. The address for the family or caregiver to respond to is printed on the letter. If the family or caregiver mistakenly sends the information to DFCS, forward immediately to AHS to the address on the letter. AHS will make a LOC determination and a disability determination, and the caseworker will proceed as follows: If approved, continue with eligibility determination process, Step 15. For applications, the caseworker will deny the case for no LOC. DO NOT SUPPRESS notice. For renewals, see Renewals below. If the family or caregiver challenges the LOC denial, the family or caregiver will send the appeal directly to DCH’s Legal Services at: Georgia Department of Community Health Legal Services Section 2 Martin Luther King Jr. Drive SE East Tower Atlanta, Georgia 30334 The appeal to DCH must be made within 30 days of the date of the LOC denial letter. When counting days, day one is the first day after the date on the letter, regardless of whether that day is a weekend or holiday. However, if the 30 th falls on a weekend or holiday, the next full business day is the 30 th day. Should the family or caregiver send the appeal to DFCS, forward the appeal to DCH’s Legal Services. The state office Medicaid Unit will notify the county if an appeal has been filed. There are no benefits to continue with a denied application. An Administrative Law Judge (ALJ) conducts the hearings for both LOC hearings and hearings for other reasons. However, requests for LOC hearings are routed through DCH Legal Services, not through OSAH. Follow the OSAH procedures ( Appendix B – Hearings TOC) for any hearing requests other than LOC. Step 12 The caseworker will do the following based on the outcome of the final LOC hearing: If the ALJ upholds the LOC denial, the case remains closed. No further action is required. However, if the family or caregiver wants to appeal the ALJ decision, see Step 13. If the ALJ overturns the LOC denial and provides a letter to that effect, the caseworker will register the Katie Beckett case again using the original application date and complete the eligibility determination process. It is not necessary to have the family or caregiver sign a new application. Proceed to Step 15 or any other step not completed. Step 13 To appeal the ALJ decision, the family or caregiver should file a written request for an agency review within 30 days of receipt of the decision to: Department of Community Health Commissioner Dr. Dean Burke Office of the General Counsel 2 Martin Luther King Jr. Drive SE East Tower Atlanta, Georgia 30334 A copy must also be sent to DCH Legal at the same address in Step 11, or they may fax a copy to 404-657-9711. Step 14 Determine the child’s suitability for care under a home care plan in lieu of institutionalized placement using the Form DMA 704 - TEFRA/Katie Beckett Cost-Effectiveness Form and the Form DMA 708 - TEFRA/Katie Beckett Worksheet . Complete a Form DMA 708 - TEFRA/Katie Beckett Worksheet as follows: Based on the approved LOC as determined by AHS, select the Medicaid cost of the appropriate institution using DCH’s provided amounts. Refer to Appendix A1 - ABD Financial Limits TOC for amounts. Base the type of institution chosen by the LOC reflected on the LOC approval letter. Subtract the physician’s estimated monthly cost of home care on the Form DMA 704 - TEFRA/Katie Beckett Cost-Effectiveness Form from the monthly Medicaid billing rate of the institution. If in-home care is more costly, deny the Katie Beckett application. If in-home care is less costly or equal to, proceed with the Katie Beckett application. Take into consideration in the cost comparison process any health or LTC insurance coverage. Do not use GAPP services or costs in the cost-effectiveness determination. This includes skilled nursing care. The caseworker should never complete the Form DMA 704 - TEFRA/Katie Beckett Cost-Effectiveness Form for the family or caregiver. If the doctor leaves any of the form blank, it is up to the family or caregiver to have it completed. Other medical entities may complete and initial the parts of the form that pertain to services they render to the A/R. Step 15 Proceed with the eligibility determination process, completing financial and other Basic Eligibility Criteria, if not already completed. Medicaid eligibility under the Katie Beckett COA is not held to the pay date shown on the LOC approval letter for new applications or LOC expirations. For new applications, the three months prior may be approved even if those months pre-date the pay date on the LOC letter. For LOC expirations, the LOC is approved from the end date of the previous LOC approval even if those dates pre-date the pay date on the LOC approval letter. The end date of the LOC is one year from the date that the LOC determination was completed by AHS, unless the LOC letter indicates otherwise. Step 16 If the A/R meets all eligibility criteria, approve Medicaid in Gateway by entering all pertinent data including any retroactive months. The system will determine financial eligibility using the Medicaid Cap and issue notification letter(s). There is no patient liability for this COA.