Government of the District of Columbia
Department of Health Care Finance

D.C. Medicaid and TEFRA/Katie Beckett: Frequently Asked Questions

General Questions

  • How is TEFRA/Katie Beckett related to District of Columbia (DC) Medicaid?
  • What services can a child get through DC Medicaid?
  • How long will the application process take?
  • Who do I contact for more information?

Eligibility Questions

  • What are the general eligibility requirements for DC Medicaid under TEFRA/Katie Beckett?
  • My child has private insurance – can we still apply for DC Medicaid?

Application Process and Documents

  • How do I apply for DC Medicaid for my child through TEFRA/ Katie Beckett? Where can I find the application materials?
  • Why do I have to submit my household income if only my child’s income is counted under TEFRA/Katie Beckett?
  • Can I apply directly to the Department of Health Care Finance (DHCF)?
  • What additional information is required for evaluation for TEFRA/ Katie Beckett?
  • Why do I need to submit the Care Plan and the Level of Care forms?
  • What is “cost-effectiveness?” How is it determined?
  • What does “institutional level of care” mean for me and my child? Am I giving up my parental rights in some way?
  • Is diagnosis alone enough to qualify for Medicaid under TEFRA/Katie Beckett? What does it mean to be disabled?
  • What types of supporting documents are helpful?

After Enrollment

  • Will my child be able to keep the same doctors he/she has been seeing?
  • Can I get reimbursed for out-of-pocket medical expenses that I’ve already paid?
  • Who will be coordinating my child’s care?
  • How do I make sure my child stays eligible?
  • How is cost-effectiveness monitored?
  • How long will my child be on the program?
  • Transitioning from TEFRA/Katie Beckett

 General Questions 

How is TEFRA/Katie Beckett related to District of Columbia (DC) Medicaid?

TEFRA/Katie Beckett is one pathway to receive DC Medicaid benefits. This eligibility category allows children who would not otherwise be eligible to enroll in DC Medicaidand receive Medicaid-covered services. Children who receive DC Medicaid through TEFRA/Katie Beckett receive the same benefits as other children enrolled in DC Medicaid.

What services can a child get through DC Medicaid?

Children enrolled in Medicaid are eligible for the“Early and Periodic Screening, Diagnostic, and Treatment” (EPSDT) services benefit. This includes all medically necessary services a child needs to take care of their basic primary care and preventive health needs, tests and screening services required to identify and diagnose any potential problems, and the care required to treat the identified concerns. Some examples of treatment could include physical therapy, occupational therapy, skilled nursing services, or other medically necessary services.Services must be medically necessary and be provided by a medical provider enrolled in the Medicaid network in order for Medicaid to cover the service.

How long will the application process take?

The process should take no more than sixty (60) days from the date of application. With your assistance in completing and returning the forms and supporting documentation as soon as possible, ESA and DHCF will work to complete your child’s applicationwithin sixty (60) days. If your child is ultimately approved and enrolled, the month of application will be the effective date for insurance through Medicaid (if not earlier, in some circumstances).

Who do I contact for more information?

If you have additional questions after reading these Frequently Asked Questions and our Application Fact Sheet, please contact:

Department of Health Care Finance

Division of Children’s Health Services

Attn: TEFRA/Katie Beckett Coverage Group

441 4th Street, NW, Suite 900S

Washington, DC 20001

Back to top of the page.

 Eligibility Questions 

What are the general eligibility requirements for DC Medicaid under TEFRA/Katie Beckett?

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

  • Be younger than 19 years old;
  • Have income less than 300% of SupplementalSecurity 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 that is typically provided in a hospital, skilled nursing facility, or intermediate care facility (including intermediate care facility 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.

My child has private insurance – can we still apply for District of Columbia (DC) Medicaid?

Yes, your child mayhave both DC Medicaid and other health insurance. The other insurance will be billed first, and then DC Medicaid provides “wrap-around” coverage for medically necessary services that your private health insurance may not cover.

Back to top of the page.

 Application Process and Documents 

How do I apply for District of Columbia (DC) Medicaid for my child through TEFRA/ Katie Beckett? Where can I find the application materials?

The first step in applying for DC Medicaid is to fill out a Medicaid application form, including information about your entire household (including income information). The application should be submitted to the Economic Security Administration (ESA), formerly known as the Income Maintenance Administration, including all documentation described on page 9 of the application.

If you identify your child as disabled on the application and ESAdetermines that your family is not eligible for Medicaid based on income, they will send your application to DHCF for further evaluation through TEFRA/Katie Beckett for your child. ESA will send you a notice telling you that Medicaid has been denied or that your family has been placed in “spend down”, but that further review will be done to see if your child is eligible under TEFRA/Katie Beckett.At this point, the DHCF Division of Children’s Health Services will contact you for more information.

All forms can be obtained by contacting either of the offices listed below or on DHCF’s website at under “Publications and Brochures.”

For more information, please contact:

Department of Health Care Finance

Division ofChildren’s Health Services

Attn: TEFRA/Katie Beckett Coverage Group

899 N. Capitol Street, NE, Suite 6037

Washington, DC 20002

(202) 442-5957

Email address:

Department of Human Services

Economic Security Administration

Attn: Medicaid Determination Division

645 H Street, NE

Washington, DC 20002

(202) 698-4220

Why do I have to submit my household income if only my child’s income is counted under TEFRA/Katie Beckett?

We must first make sure that your child isn’t eligible for District of Columbia (DC) Medicaid under another eligibility category, which includes being eligible because of family household income. The application process for a family that’s eligible because of income is much easier than applying for DC Medicaid under TEFRA/Katie Beckett because of the medical documentation necessary under TEFRA/Katie Beckett. We have found some families apply for Medicaid under TEFRA/Katie Beckett, and then realize they were already eligible as a family because they were within the qualifyingincome for DC Medicaid. In 2012, the household income limit for a family of four is $69,150 per year.

Can I apply directly to Department of Health Care Finance (DHCF)?

No. Applications must be submitted to the Economic Security Administration (ESA) (formerly the Income Maintenance Administration (IMA)). ESAis the agency responsible for eligibility determinations for all public benefit programs in the District of Columbia. Applications may be submitted in person to any of the ESAservice centers or may be mailed to the Medicaid Unit of IMA at 645 H Street, NE; Washington, DC 20002.

What additional information is required for evaluation for TEFRA/ Katie Beckett?

If your child is being evaluated for DC Medicaid eligibility through TEFRA/ Katie Beckett, the Department of Health Care Finance, Division of Children’s Health Services will contact you for more information. DHCF will need to know about your child’s disability and the care he or she needs. You will be given two forms that need to be completed with your child’s doctor—the Care Plan and the Level of Care form. These must be completed and signed by your child’s doctor and returned to DHCF along with any supporting documents. Supporting documents may include medical records; evaluations done by a doctor, therapist, or other specialist; an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP); and/or any other documents that will help us understand and evaluate the services your child needs.

Why do I need to submit the Care Plan and the Level of Care forms?

The Care Plan and Level of Care forms are designed to explain your child’s needs and the Level of Care he or she requires. They also help DHCF determine whether or not the care needed meets the Medicaid requirements for cost-effectiveness.

TEFRA/ Katie Beckett is designed to support families by providing services at home for children who mightotherwise need to be in an institutional care setting. Therefore, to be eligible for Medicaid through TEFRA/ Katie Beckett, your child must require an “Institutional Level of Care.” This means that he or she must require the type of care traditionallyprovided in a hospital, nursing home, or intermediate care facility (ICF/ID). These two forms, along with any supporting documents, help us evaluate whether or not your child meets the Level of Care criteria and, if so, whether care can be safely and cost-effectively provided at home.

What is “cost effectiveness?” How is it determined?

To be eligible for Medicaid through TEFRA/ Katie Beckett, Department of Health Care Finance must determine that your child’s care at home will not cost DC Medicaid more than if your child was being cared for in a hospital, nursing home, or intermediate care facility (ICF/ID).

DHCF uses the information on the Care Plan you submit to determine cost-effectiveness. DHCF adds up all of the Medicaid costs for the services described in the Care Plan and then compares that total to what Medicaid would pay if your child were being cared for in an institution. As long as the Medicaid costs for the Care Plan are less than the cost of institutionalization, the application meets cost-effectiveness. After enrollment, the cost-effectiveness of your child’s case will be periodically reviewed and monitored.

What does “institutional level of care” mean for me and my child? Am I giving up my parental rights in some way?

The levels of care criteria for these institutions are used onlyas a review tool and will not infringe on your parental rights or your decision to care for your child with in your home. Institutional level of care is a term used to categorize the healthcare services that an individual might require based on their medical needs. There are three types of institutions considered during the review process: hospitals, pediatric nursing facilities and intermediate care facilities.

Is diagnosis alone enough to qualify for DC Medicaid under TEFRA/Katie Beckett?

No, diagnosis alone is not enough to quality for DC Medicaid under TEFRA/Katie Beckett. There are several components to the qualification process under TEFRA/Katie Beckett. The first qualification is the eligibility determination based on income of your child; the second qualification is the level of care determination, which takes into consideration the child’s diagnosis and disability status, as well as the extent of your child’s medical needs; and, the third qualification is the determination of cost effectiveness, indicating cost savings to care for your child in the home rather than in an institution.

What types of supporting documents are requested?

Supporting documents are key to the review process. It is important that the documents are current, fully and accurately completed, and appropriately signed by the individual submitting the documents, such as the parent/guardian or service professional. Requested documents would include the physician or nursing clinical evaluations, Individualized Education Program (IEP) or the Individualized Family Support Plan (IFSP), and therapy summaries, such as physical therapy, occupational therapy, and speech and language therapy.

Back to top of the page.

 After Enrollment 

Who will be coordinating my child’s care?

If your child is found eligible for Medicaid under TEFRA/Katie Beckett, your child is able to enroll in Medicaid through one of two networks:

  • Fee-for-Service Medicaid, or
  • Health Services for Children with Special Needs (HSCSN),

Children under TEFRA/Katie Beckett areautomatically enrolled in fee-for-service Medicaid. In fee-for-service, providers contract directly with DC Medicaid. DC Medicaid staff can assist you with finding providers who are enrolled in DC Medicaid.

HSCSN is a managed care organization that has a specific network of providers for its enrollees and offers 24-hour access to care coordination and individualized case management. HSCSN also provides some additional benefits, including respite care and medically necessary home modifications. As a Medicaid managed care plan, HSCSN works with providers to authorize needed care and to ensure that treatments are medically necessary and evidence-based. These services are provided free-of-charge to your family if you choose to enroll your child in HSCSN.

DC Medicaid has asked HSCSN to reach out to all families who have a child enrolled in Medicaid under the TEFRA/Katie Beckett eligibility category. You do not have to meet with the HSCSN representative if you do not want to, but if you want your child to be enrolled in HSCSN, you must request to be enrolled.

Will my child be able to keep the same doctors he/she has been seeing?

In order to be reimbursed by District of Columbia (DC) Medicaid, your doctors need to be enrolled either directly with D.C. Medicaid or with HSCSN. This is true even if your child has other insurance that is the primary payer and Medicaid is just paying the co-payment.

Can I get reimbursed for out-of-pocket medical expenses that I’ve already paid?

If you have already paid, or are currently paying, a bill for medical services your child received up to three months before you applied for and were approved for Medicaid, Medicaid may be able to pay you back or pay the medical provider. You need to fill out a Medicaid Reimbursement Form. A copy of the form is available at under Recipient/Forms. You can also contact the Health Care Operations Administration at (202) 698-2009 to request a form. Only medically necessary services that Medicaid would have paid for will be reimbursed.

How do I make sure my child stays eligible?

DC Medicaid requires that all beneficiaries be re-evaluated for financial and clinical eligibility on an annual basis. This is called “recertification” and includes new level of care and cost-effectiveness determinations.

When your child has been enrolled for almost one year, DHCF will send you a packet of materials for recertification. ESA will also send you the eligibility re-certification form. Make sure to complete and return ALL the forms toDHCF as soon as possible so that there is no break in your child’s Medicaid enrollment.

How is cost-effectiveness monitored?

As part of monitoring the financial component of the eligibility criteria, DHCF will be tracking the costs to Medicaid for services provided to your child. If the costs to Medicaid exceed the estimated costs of serving your child in an institution, DHCF will contact you. If the costs of providing care continue to exceed the cost of serving your child in an institution, then your child will be disenrolled from the Medicaid program.

How long will my child be on the program?

Eligibility under TEFRA/Katie Beckett lasts until your child’s 19th birthday as long as your child remains eligible based on his/her health care needs and the cost to Medicaid does not exceed the limit.Your child will be re-evaluated every year for continued eligibility under Medicaid.

What transition planning can I expect?

One year prior to your child’s 19th birthday, DHCF will help you develop a transition plan to explore other service resources to support your child’s medical needs as an adult, such as applying for SSI.

Back to top of the page.

DHCF, HCDMA, Division of Children’s Health Services –Revised December2012, pg. 1