How to fill out the Katie Beckett

Transcription

How to fill out the Katie Beckett (Deeming Waiver/TEFRA) Medicaid Forms
By Raissa Chandler
Fayetteville, Georgia
Email: [email protected]
This was my journey through getting Katie Beckett. I have twins with autism who
currently qualify for the ICF/MR level of care criteria for Medicaid. I have to do this once for
each twin yearly and figured out a system to get me organized and transmitted back to DFCS
faster. This is my system. Feel free to contact me at the above email if you have any questions.
We use Medicaid primarily to reduce the cost of prescription medication, override
copays, dental services, and qualify for the HIPP program, which pays our out of pocket
premium cost of primary insurance through my husband’s work. Because we have a Medicaid
number, both my children are on the waiting list for the NOW/COMP waiver, which is another
Medicaid waiver that can help pay for other costs associated with our diagnoses.
This is not the only system out there. There are Medicaid consultants who can take you
through the process. You can find them on the Parent to Parent of Georgia Special Needs
database here. Search on “Insurance Deeming Waiver”.
Parent to Parent of Georgia also has training on this subject online in two places on their
website (www.p2pga.org).
1. Click here to go to the Medicaid Waiver page of the Roadmap.
2. Click here to view an archived webinars from Debbie Dobbs about filling out the
Deeming Waiver. Look for the Deeming Waiver ones.
If this booklet has been helpful in your journey, please drop me a line and let me know.
I’m personally trying to help 100 families through this process, and I hope you’ll let me know if
I’ve helped you.
General Steps...............................................................................................................................2
A Finished Package Checklist.....................................................................................................4
Doctor’s Letter of Medical Necessity Example...........................................................................5
Medical History Attachment Example.........................................................................................6
Executive Summary Example (Level of Care = Nursing Home)................................................7
NAME:..........................................................................................................................7
DFCS Case/Client No _____________.............................................................................7
Executive Summary Example (Level of Care = ICF/MR)..........................................................8
Child’s Name................................................................................................................8
DFCS Case/Client No _____________.............................................................................8
Form Examples – Specific to AUTISM diagnosis......................................................................9
Pediatric DMA 6(A)................................................................................................................9
DMA 704 Cost Effectiveness Form.......................................................................................10
DMA 706 Care Plan...............................................................................................................11
Page 1 of 14
This is my journey through Katie Beckett. Others have had different experiences.
Raissa Chandler email: [email protected]
How to fill out the Katie Beckett (Deeming/TEFRA) Waiver Medicaid Forms
© 2010 Raissa Chandler
General Steps
Step 1: Call SSI toll free (800) 772-1213 and get a determination on whether your child with a
disability can qualify for SSI. If they do, you bypass Katie Beckett and get into the state’s
Medicaid system faster. Schedule a phone appointment instead of going and waiting at Social
Security Offices. (This takes up to two hours, depending on how long you have to wait on hold.)
Step 2: Pick up forms at local DFCS office. Only the Katie Beckett/Deeming Waiver caseworker
will have the right packet. (This takes less than 15 minutes.)
Step 3: Collect your records (This takes a couple of hours)
1. Financial information like cars, insurance policies, bank statements
2. Medical information like dates of hospitalization, major illnesses, doctors’ names and
addresses
3. Evaluation information like Babies Can’t Wait Evaluation, Psychological Evaluation,
Therapeutic Evaluations (Speech, OT, Physical Therapy)
4. Plans like IFSP or IEP
Step 4: Start filling out forms while you wait for SSI Determination. Don’t date anything. (This
takes 4 – 8 hours the first time you do it, but only about 2 hours in future years).
1. Start with financial, citizenship, TANF, HIPPA, Insurance forms. These are NOT
intimidating – you’ve seen similar ones when applying for a credit card. Regardless of
what the form says, fill out what the family’s resources are and specify who owns the
resource.
2. Fill out the medical ones so your doctor only has to sign them. Leave the dates blank. The
final date you fill in determines when the next reapplication is due, so you want it to be as
late as possible. Note that you’ll need to draft a letter of Medical Necessity, which is not
part of the application form.
a. On the Pediatric DMA 6(A), Box #18 – Level of Care – is one of the key review
points that determine if you qualify for KB. If you don’t know what level of care
to check, ask someone.
b. Ask around to see if you can find a family with a child with a similar disability
who has already been approved and copy stuff from their application onto yours.
c. Ask me if I have a similar marked up copy that you can copy from.
d. Schedule a phone appointment with me or someone who does Katie Beckett help
to help you fill out the forms step by step, specific to your child. You can find a
list of providers by accessing the Parent to Parent of Georgia Special Needs
database here. Look under “Insurance – Deeming Waiver”.
3. Take the medical forms and history to your doctor to sign but not date them. (Usually
quick turn around time from the doc’s office since you’ve already filled them out.)
4. Make an executive summary or checklist of where documents are so that the Medicaid
Reviewer can make a quick determination.
Page 2 of 14
Step 5: Once SSI determination letter has been received, package and deliver your application.
Travel to and from stores varies. Copying takes at least ½ hour. Putting it all together will take at
least an hour.
1. Get a Certified Mailing slip from the Post Office. You’ll also have to return to the
post office to mail it off. Put the Certified Mailing Number on your Executive
Summary or cover letter to keep track of the document.
2. Get a binder capable of holding all the paperwork you’ve gathered and filled out. For
initial submittals, count on at least a 2 inch binder.
3. Get 3 section dividers to section out important parts of the forms.
4. Get sticky notes or specialty tabs to guide the reviewer to the applicable forms. For
example, you should put a sticky note on the first page of the IEP so that the reviewer
can find it quickly.
5. Use the checklist to put it all together. Don’t forget to date all those places you left
blank. Use the date that you are mailing off through the post office.
6. Take completed package to copy place and make a copy of all the documents for your
records. Expect that at some time your submission will get lost and you may have to
resubmit everything. In 5 years, this has happened to me 3 times with my twins.
7. Take completed package to Post Office and mail to DFCS office through Certified
Mail. It may cost over $10, but offers you the protection that the package was
delivered and received through “government” channels.
Step 6: Wait. Depending on the time of year, the wait could be short or long. Start calling the
DFCS office after the 3rd week out to see if your child has a Medicaid Number. Bug them every
week until you get some type of determination. You just need to have the Medicaid number in
the system in order for therapists to bill against it. You don’t have to wait to get the official
letter.
Step 7: If your child is too high functioning to qualify for Katie Beckett and a Final
Determination Denial letter says so, you have the right to appeal the decision, or you can reapply
the next day or you can seek different supports through the Champions for Children medical
scholarship fund. The Champions fund caps off at $2,500 per year. The telephone number of the
intake office for this scholarship is toll free (800) 365-4583 or (866) 584-3742.
If you get denied for another reason, it’s best to ask around for help to figure out what to do next.
In my situation, the first time I got a denial, I got too angry and responded inappropriately; when
all I really needed to do was reapply with additional information.
Page 3 of 14
A Finished Package Checklist
Cover Letter with a picture of your child and the Certified Mail Number
Tab 1: Financial/Citizenship Information
1. Application Forms
a) Form 94 – Application for Medicaid or Form 222 Medicaid Renewal Form
b) DMA Form 285 Health Insurance Questionnaire
c) Form 5460 Notice of Privacy Practices
d) Form 297(A) Signature page
e) Declaration of Citizenship/Alien Status
f) DHR Form 219 Affidavit of Facts Concerning Citizenship
2. Last two pay stubs for everyone who works in the house
3. Last IRS Tax forms for everyone in the house
4. Medical Health Insurance Card
5. Denial letter from SSI
6. The latest Savings, Checking, and Credit Union statements
7. The latest IRA/401K/Retirement statements
8. Titles to anything you own or are paying off: cars, trucks, equipment, houses
9. Life Insurance Policies
10. Latest payments given to you for anything – unemployment, workers comp, student
loans, trust funds, dividends, child support
11. Latest expenses billed to you for anything – credit cards, utilities, taxes
Tab 2: Medical Forms
1. Executive Summary (the checklist to guide the reviewer’s eye to the right things)
2. Application forms
a) Pediatric DMA-6(A), Physician’s Recommendations for Pediatric Care
b) DMA Form 706 Care Plan
c) DMA Form 704 Cost Effectiveness Form
d) DHR Form 188 Social Data Report (if applicable in your county)
3. Supporting documents to the application form – Additional Medical History or other
attachments.
4. Doctor’s Letter of Medical Necessity (on the doctor’s letterhead)
Tab 3: Additional Supporting Documents – put sticky notes on sections that demonstrate the
number of therapeutic sessions per week, like on the page of the IEP that spells out 2 sessions of
Occupational therapy per week. Also, put sticky notes on the pages that have numerical results to
evaluation tests (like IQ or Speech scores).
1. Latest Psychological Exam (from School or Babies’ Can’t Wait) (can’t be more than 3
yrs ago)
2. IEP (Individual Education Plan) or IFSP (Individual Family Support Plan)
3. Any medical/mental/therapy evaluations
4. Statement from each therapist noting present level of functioning (1 page status report)
Page 4 of 14
Doctor’s Letter of Medical Necessity Example
Leave a two inch margin at the top and ask your doctor to copy on their medical stationery and sign.
June 22, 2009
Georgia Medical Care Foundation
57 Executive Park Drive South
Suite 200
Atlanta, Georgia 30329
RE:
TEFRA/Deeming Waiver Renewal
Letter of Medical Necessity
Your child’s name
Dear TEFRA Review Nurse:
This is to certify that I have reviewed __child’s name___ medical records. S/he has
diagnoses of an autism spectrum disorder, and ___list other diagnoses__. In order for
her/him to reach his potential in a community and family-centered environment, I certify
the following to be medically necessary and accurate:
• Intensive, ongoing individual psychotherapy or behavioral therapy 5 – 7 sessions
per week to address ongoing aggression, non-compliance, tantrumming, and
reduction of OCD tendencies. In addition, behavioral therapy should increase
personal adaptive, social, and self determination skills
• Individual, ongoing speech and language therapy 2-3 sessions per week to address
pragmatic and social communication deficiencies
• Individual, ongoing occupational therapy 1-2 sessions per week to address gag
reflex, sensory integration, self care skills, and fine motor deficiencies.
• Use of aqua therapy, music therapy, or hippotherapy modalities to ameliorate
sensory dysfunction or increase social pragmatic speech, based on his/her interest
in these areas.
If I can be of further assistance, please contact me at my office.
Sincerely,
Your doctor’s name, MD
Pediatrician
Page 5 of 14
Medical History Attachment Example
The Medical History Attachment to the DMA 6(a) form lists the major milestones/setbacks you
have experienced. You can add on to this narrative from year to year. As a way to track what has
happened over the year, you may want to keep a file folder of all the superbills you get when
checking out of the doctor’s office. I usually write on the backs of them to list why we went to
the doctor, or what kind of procedure was done. The superbill will list who your child saw, the
date seen, and any procedures they used (lab tests, screenings). An example of medical history is
below.
Crucial history you will want to highlight is dates of diagnosis, any hospitalizations, any major
illnesses, any new or changes in therapy or medication.
Name of child
Date of Birth: 4/12/02
Date
4/12/02 – 4/30/02
1/1/03
1/23/03
2/14/03
12/29/03
1/15/04
2/20/04
3/14/05
6/14/05
9/22/05
What happened
Premature, Blue at birth, kept in
NICU until breathing stabilized and
stats were OK
ER visit - major ear infection over
the holiday
Ear infection
Ear infection
Trip to ER – swallowed something
that constricted airway
Trip to ER – climbed on top of
something that fell back – broken
foot
Bronchitis
Surgery – removed adenoids and
tonsils
Started wheezing, started seeing
allergist for asthma
Trip to ER – broke arm when
jumping off playground equipment
Page 6 of 14
Outcome
Discharged
Put on antibiotics
Put on antibiotics
Put on antibiotics – asked
doctor for other options
besides antibiotics –
researching tubes
Item removed.
Cast for 8 wks
Antibiotics
Discharged
Placed on inhaler and
puffer.
Cast/PT 7 weeks
Executive Summary Example (Level of Care = Nursing Home)
MEDICAL Summary FOR ACS/DCH - TEFRA/KB Deeming Waiver
Medicaid ID Applied
NAME:
Age:
Diagnosis:
DFCS Case/Client No _____________
Parent Information
Name:
Address:
Caseworker Name –
Telephone –
Load –
Phone:
Email:
This summary outlines the location of documents within this report that demonstrate our child’s continual need for Medicaid services under the
TEFRA/Katie Beckett deeming waiver.
Under the deeming waiver criteria 42 CFR 435.225,
(1)
My child requires the level of care provided in a Skilled Nursing Facility.
Our child meets the following conditions for Nursing Facility institutional level of care.
From Column A, Section I – My child requires the use of the following items on a continual basis, seven days a week:
#
Description
Frequency
A.I.d
EXAMPLE: Enteral feeding that comprises at least 26 per cent of daily calorie
requirements and provides at least 501 milliliters of fluid per day
From Column A, Section 2 – My child requires a mix of therapies that total five days per week.
Description
A.II.b
Therapeutic exercises and activities performed by PT or OT
A.II.c
Gait evaluation and training to restore function to a patient whose ability to walk has been
impaired by neurological, muscular, or skeletal abnormality
A.II.d
Range of motion exercises which are part of active treatment of a specific condition which
has resulted in a loss of, or restriction of mobility
A.II.h
Services of a speech pathologist or audiologist when necessary for the restoration of
function in speech or hearing
Times per week
From Column B, a doctor’s letter of medical necessity indicates a need and an order for the above services. This is attached to the Daily Care
Plan.
(2)
My child can be provided with the needed level of care based at home, rather than in an institution.
Our child is undergoing treatments and therapies at least five days per week. These therapies are based in home or at school, rather than in an
institution. (42 CFR 435.225, 42 CFR 409.31-34). Refer to the charts above regarding frequencies of treatments.
(3)
The total estimated Medicare cost for services provided based at home is less than the estimated Medicaid cost of
appropriate institutional care.
Refer to the Cost Effectiveness Form.
Page 7 of 14
Executive Summary Example (Level of Care = ICF/MR)
MEDICAL Summary FOR ACS/DCH – TEFRA/KB Deeming Waiver
Child’s Name
Age:
Diagnosis: Autism
Parent: XXX
111 First Street
Hampton, GA 30228
(XXX) XXX-XXXX
Email: [email protected]
Medicaid ID Applied
DFCS Case/Client No _____________
Caseworker Name –
Telephone –
Load –
This summary outlines the location of documents within this report that demonstrate my child’s continual need for Medicaid services under the
TEFRA/Katie Beckett deeming waiver.
Under the deeming waiver criteria 42 CFR 435.225,
(2)
My child requires the level of care provided in a Intermediate Care Facility.
My child meets the following conditions for ICF/MR institutional level of care.
From Column A, Section 3 – My child has a diagnosis of Autism/Autism Spectrum/Asperger’s, PDD-NOS, Down’s Syndrome, or Developmental
Delay and
(Section 4) Has measured scores to indicate substantial limitations [(4i)less than 2 standard deviation or overall composite less than 70, or (4ii)
age equivalency composite score is less than 50% of their chronological age] in three or more of the following functional limitations. These
scores are based on standardized or adaptive functioning tools and can be found under indicated tabs:
Domain
Name of Test
Dated
Given by
Communication
PLS4
Xx/xx/xxxx
Name, CCC-SLP
Mobility
Self Care
Self Direction
Age Appropriate Ability to Live
OR
(4iii) My child’s CARS score over 37, GARS score over 121, or standardized autism score indicates severe autism. Test
________________________ _____________ Score ___________________ Date ____________________ Given by:
___________________________, PhD
From Column B, condition b. – My child requires a mix of therapies that are performed or supervised by technical or professional personnel at
least five days per week. The following therapies are used with my child.
Description
Times per week
Behavioral Therapy
5 times per week – school
1 time per week – clinic
Speech Therapy
Occupational Therapy
Psychotherapy
Other
From Column C, a doctor’s letter of medical necessity indicates a need and an order for the above services. This is attached to the Daily Care
Plan.
(2)
My child can be provided with the needed level of care based at home, rather than in an institution.
Our child is undergoing treatments and therapies at least five days per week. These therapies are based in home or at school, rather than in an
institution. (42 CFR 435.225, 42 CFR 409.31-34). Refer to the charts above regarding frequencies of treatments.
(3)
The total estimated Medicare cost for services provided based at home is less than the estimated Medicaid cost of
appropriate institutional care.
Refer to the Cost Effectiveness Form.
Page 8 of 14
Form Examples – Specific to AUTISM diagnosis
Pediatric DMA 6(A)
Page 9 of 14
DMA 704 Cost Effectiveness Form
Page 10 of 14
DMA 706 Care Plan
Page 11 of 14
Page 12 of 14
Page 13 of 14
Page 14 of 14

How to fill out the Katie Beckett

Transcription

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