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Law 421 Children’s Medicaid Option (421-CMO)

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Bill 421 of the 2019 regular legislative session instructed the Louisiana Department of Health to initiate a program allowing certain children with disabilities to receive Medicaid coverage, even if their parents earn too much money to be eligible for Medicaid. Medicaid. Children with Disabilities Living at Home with Their Families Applying for Law 421-CMO to have to meet an institutional level of care for an intermediate care facility for people with developmental disabilities (ICF/IID), nursing facility, or hospital to be considered for this program.

Law 421 created what is called a TEFRA option in Medicaid. TEFRA refers to the Tax Equity and Fiscal Responsibility Act of 1982, which is a United States federal law that can help families with children under 19 with disabilities receive care at home rather than in an institution. TEFRA programs are sometimes referred to as the Katie Beckett Program or Katie Beckett Waiver in other states. In Louisiana, the program is Law 421 Children’s Medicaid Option (Law 421-CMO).

Louisiana Medicaid has received approval from CMS to implement the program as a modification to the state plan. The program came into effect on January 1, 2022.

To be eligible for the Loi 421-CMO option, a child must meet all of the following eligibility criteria:

  • Be a resident of Louisiana.
  • Be a US citizen or qualified non-citizen.
  • Under 19 (not to exceed the age of 18).
  • Has a recognized disability under the definition of disability used in the Social Security Administration’s Supplemental Security Income program, whether or not the child is eligible to receive benefits under this program.
  • Excluding the assets (resources) of the parents, the child does not have total assets (resources) greater than $2,000 in value.
  • Excluding the parents’ income, the child’s income is less than three (3) times the Federal Benefit Rate (FBR), referred to as the Individual Special Income Limit (SIL).
  • The child responds to an institutional level of care provided in a hospital, skilled nursing facility, or intermediate care facility (ICF).
  • Care delivered safely at home for less than the cost of residential care.

Enrollment in the Loi 421-CMO program involves four (4) general steps. In order to begin the enrollment process, complete a Medicaid application and submit verification documents. Coverage for 421-CMO cannot begin until January 1, 2022, when the program went into effect. You can view the ACT 421 CMO/TEFRA application process here.

Step 1. Complete a Medicaid Application

There are four (4) ways to apply for Medicaid – online, by mail, in person, or by phone. Choose the method that works best for you.

  1. Apply online.
  2. To apply by phone, call 1-888-342-6207.
  3. To apply in person, locate the nearest application center here or the regional Medicaid office here.
  4. If applying by mail, download the Medicaid application. The completed application can be faxed to 1-877-523-2987 or mailed to:

Health Insurance Claims Office

Box 91278

Baton Rouge, LA 70821-9893

IMPORTANT: You must select a health plan at this stage of the process. If you don’t choose a health plan, a plan is randomly assigned. For more information on selecting a health plan, visit: https://www.myplan.healthy.la.gov.

When applying online, you must check the box next to the applicant with a disability on the Additional Personal Details screen:

After selecting which candidate has a disability, the next screen asks for additional disability information. Choose Disabled from the drop-down list:

When using a paper application to apply, the disability question (as noted in Question 10 below) must be answered “yes” to be routed to 421-CMO processing:

Applicants deemed ineligible for other Medicaid or CHIP programs who meet all other 421-CMO criteria proceed to Stage 2 of the enrollment process

Step 2. Assessing the level of care in your district/social services authority

Your district of social services must perform an assessment to determine if the applicant meets the level of care requirements. You will receive a Level of Care Record, which contains documents to complete and return to LDH. All forms must be completed completely, supporting documentation provided (if applicable) and returned to LDH in a timely manner.

Families will receive an application to complete and return to Medicaid. The forms you receive depend on the level of care pathway deemed appropriate for your child. Your package may contain these documents:

The District of Social Services completes the assessment by reviewing the information and forms provided by the applicant to it is important to follow the instructions in the level of care package when filling out the forms.

Submit the completed level of care packet to Medicaid to upload to the eligibility system via:

  • Fax to: 1-225-389-8019
  • Email to: [email protected]
  • Mail to: Medicaid Claims Office; 6069 1-49 Service Road, Suite B, Opelousas, LA 70570.

Or

  • Upload documents directly to your Medicaid account using the Self-Service Portal. Instructions on how to upload documents to your account can be found here.

Applicants who meet the level of care requirement proceed to Step 3 of the registration process.

Step 3. Determination of disability

Applicants must meet the definition of disability as set forth by the Social Security Administration. Medicaid will request a disability determination from the Medical Eligibility Determination Team (MEDT) for applicants who do not have a disability determination from the Social Security Administration office. MEDT may need additional documentation in order to make a decision on the disability determination.

If you would like assistance in gathering the necessary medical records, you can sign a Authorization Form to Disseminate or Obtain Health Information (HIPAA 202L) obtain these records directly from the providers (doctors, home health, social service, etc.) found in the level of care package. This form is used to help you obtain the medical records needed to determine if your child meets the level of care and disability requirements for the 421-CMO program.

Applicants who meet the disability requirement proceed to Stage 4.

Step 4. Enrollment/Coverage of Services through a Healthy Louisiana Plan

Applicants meeting the medical and financial requirements will receive Medicaid coverage through a Healthy Louisiana plan. When you apply for Medicaid, you can choose a Healthy Louisiana health and dental plan. If you have not selected a health plan, enrollment in a health plan is automatic when enrolling in Medicaid. Family will have 90 days from date of enrollment to change plans when auto-enrollment occurs.

If your child is enrolled in the 421-CMO Law Program (TEFRA), LaHIPP may pay for your individual insurance plan or employer-sponsored insurance, subject to an annual cost-effectiveness review.

You can apply for LaHIPP here. Download the application and submit one of three ways:

  • Email: [email protected]
  • Fax: 1-855-618-5486
  • Mail: LDH ATTN: LaHIPP PO Box 91030 Baton Rouge, LA 70821-0930

IMPORTANT: If you are approved for LaHIPP, your child will be unenrolled from the Healthy Louisiana Plan (MCO) for physical health services, but will remain enrolled for behavioral health services and NEMT (non-emergency medical transportation). Physical health services will be covered by fee-for-service (also known as traditional Medicaid).

This can affect whether your provider accepts your Medicaid coverage. Before enrolling in LaHIPP, you can use the “Find a Provider” tool to see if your child’s doctor will accept Medicaid with LaHIPP. The tool can be found here: https://www.lamedicaid.com/apps/provider_demographics/provider_map.aspx.

Please see the Law 421 FAQ for more information on LaHIPP.

For more information, visit the LaHIPP website.

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