Katie Beckett / TEFRA Guide for Tennessee

What Is Katie Beckett / TEFRA?

• Katie Beckett is named after a child whose family fought for Medicaid coverage when parental income made her ineligible.
• Under the TEFRA option (Tax Equity and Fiscal Responsibility Act), states can cover children who are medically complex — regardless of their parents' income.
• Only the child's own income and assets are counted. Since most children have little to no income, they typically qualify financially.
• The child must be under 18 and have a disability or medical condition that would normally require institutional care (hospital or nursing facility).
• This is a lifeline for middle-income and higher-income families who have a child with serious medical needs.

Why It Matters

• Regular TennCare eligibility counts the entire family's income — so families earning above the limit are shut out.
• Katie Beckett ignores parental income entirely. Only what the child earns matters (which is usually nothing).
• This means a family earning $80,000 or $150,000 a year can still get TennCare for their medically complex child.
• TennCare through Katie Beckett covers medical services that private insurance often limits or denies — like extensive therapy, nursing care, durable medical equipment, and home health services.
• It can also serve as secondary insurance alongside private coverage, picking up costs that the private plan does not cover.

Qualifying Conditions

• The child must be under 18 years old.
• The child must meet Social Security's definition of disability OR need an institutional level of care.
• Institutional level of care means the child's medical needs are serious enough that they would otherwise require care in a hospital, nursing home, or other facility.
• Examples include: severe cerebral palsy, complex congenital heart conditions, ventilator dependence, severe autism with high support needs, cancer requiring ongoing treatment, serious intellectual or developmental disabilities, and other conditions requiring extensive medical care.
• The child does not need to actually be in an institution — the point is that they COULD need one without the support services.

How to Apply

• Call TennCare Connect at 1-855-259-0701 and ask about Katie Beckett/TEFRA eligibility for your child.
• You can also apply through the Tennessee Department of Human Services (DHS) at your local office.
• Gather your child's medical records — diagnosis, treatment plans, therapy records, hospital stays, specialist reports.
• A disability determination will be made based on the child's medical documentation. This can go through SSI or TennCare's own process.
• If your child already receives SSI, they are automatically eligible for TennCare — you may not need the Katie Beckett pathway.
• The application process can take time, so apply as soon as you know your child may need this coverage.

ECF CHOICES for Intellectual/Developmental Disabilities

• Employment and Community First CHOICES (ECF CHOICES) is a separate TennCare program specifically for people with intellectual and developmental disabilities (IDD).
• ECF CHOICES provides: employment supports, independent living skills training, community participation, respite care, assistive technology, and more.
• If your child has an intellectual or developmental disability (such as Down syndrome, autism, or intellectual disability), ask about ECF CHOICES in addition to Katie Beckett.
• ECF CHOICES has a waiting list, so apply early.
• Contact the Tennessee Department of Intellectual and Developmental Disabilities (DIDD) at 1-615-532-6530 for more information.

SSI vs Katie Beckett — Which Path Should You Take?

• Both SSI (Supplemental Security Income) and Katie Beckett/TEFRA can get your child onto TennCare. The right choice depends on family income and the child's situation.
• TAKE THE SSI PATH IF: family income is low enough to qualify (roughly under $3,500/month gross for a family of 3, but varies by household size and disability-related expenses). SSI eligibility AUTOMATICALLY enrolls your child in TennCare — no separate Katie Beckett application needed. SSI also provides a monthly cash benefit (up to $943/month in 2025).
• TAKE THE KATIE BECKETT PATH IF: family income is too high for SSI (most middle-class and higher-income families). Katie Beckett ignores parental income entirely — only the child's own income counts. Most kids have no income, so they qualify financially even if parents earn $80K, $150K, or more.
• APPLY FOR BOTH IF UNSURE: a denial from SSI does NOT block a Katie Beckett application. Many families try SSI first (faster path if approved), then pivot to Katie Beckett if income disqualifies them.
• KEY DIFFERENCE: SSI requires meeting Social Security's strict disability definition. Katie Beckett requires meeting the institutional level-of-care standard — different criteria, sometimes easier to meet for kids with serious medical needs but less obvious cognitive/functional impairment.
• If your child already has an SSI determination on file, mention it in any Katie Beckett application — it strengthens your case.

What to Expect — Application Timeline

• STRAIGHTFORWARD CASES: 60-90 days from application submission to approval decision.
• COMPLEX CASES (level-of-care disputes, missing documentation, IDD evaluations needed): 4-6 months is typical.
• WEEK 1-2: TennCare acknowledges receipt of application. You'll get a letter or portal notification with a case number. SAVE THIS.
• WEEK 2-4: Documentation review. TennCare will send a request for additional info if anything is missing. Respond within 10 days or your case may be closed. Common requests: bank statements, pay stubs, expanded medical records, school IEP if applicable.
• WEEK 4-8: Level-of-care assessment. For Katie Beckett, a TennCare-contracted reviewer evaluates whether your child meets institutional level of care. This is the most common point of denial. The reviewer looks at: hours of skilled care needed daily, dependence on medical equipment, behavioral support requirements, cognitive functioning. Be specific in your documentation.
• WEEK 8-12: Final decision letter. If approved, TennCare coverage typically begins the first of the following month. If denied, you have 30 days to appeal — see our Denied? Appeals Guide.
• EXPEDITED REVIEW: if your child has a medical emergency (newly diagnosed, hospital discharge pending, urgent surgery), call TennCare Connect at 1-855-259-0701 and request expedited processing. Decisions in 72 hours possible.
• RETROACTIVE COVERAGE: in some cases, TennCare can cover medical bills incurred during the application processing period. Ask specifically about this during application — many families don't know and miss out.

Services Available Through TennCare

• Skilled nursing care — in-home or facility-based nursing services.
• Physical, occupational, and speech therapy — often with higher limits than private insurance.
• Durable medical equipment (DME) — wheelchairs, hospital beds, communication devices, orthotics.
• Prescription medications — covered through TennCare's pharmacy benefit.
• Home health services — nursing and aide visits in your home.
• Respite care — temporary relief for family caregivers.
• Medical supplies — feeding supplies, incontinence supplies, wound care, and more.
• Transportation to medical appointments.
• Mental health and behavioral health services.

Side-by-Side — Katie Beckett vs ECF CHOICES vs SSI

• KATIE BECKETT / TEFRA: For children under 18 with a disability OR institutional level of care need. Ignores PARENTAL income — only child's own income counts. Covers full TennCare benefits (medical, therapy, DME, home health). Open enrollment — no waiting list. Best for: middle/higher-income families with medically complex children.
• ECF CHOICES: For people with intellectual or developmental disabilities (IDD) — including autism, Down syndrome, intellectual disability. Provides employment supports, community living, day services, respite, assistive tech. WAITING LIST — apply early even if you're not ready to use services. Best for: kids/adults with IDD diagnosis who need long-term community support, not just medical care.
• SSI (Supplemental Security Income): Cash benefit (up to $943/month in 2025) + automatic TennCare enrollment. Requires meeting SSA's strict disability definition AND family income/asset tests. Best for: lower-income families whose child has a clear SSA-recognized disability.
• OVERLAP: A child with autism + serious medical needs in a middle-income family might qualify for ALL THREE — Katie Beckett for TennCare medical coverage, ECF CHOICES for community supports, and SSI may not apply due to income. A non-verbal child with severe IDD in a low-income family might be on SSI (auto-TennCare) + ECF CHOICES waiting list.
• RULE OF THUMB: Start with Katie Beckett if income is high. Start with SSI if income is low. Apply for ECF CHOICES regardless if there's an IDD diagnosis — the waiting list can take years.
• DON'T LET ANYONE TELL YOU TO PICK JUST ONE. These programs work together. A TennCare worker who says 'you have to choose' is wrong. Apply to all that fit.

Autism & Behavioral Health — What's Specific to These Families

• Autism is one of the most common Katie Beckett-qualifying conditions in Tennessee. Diagnosis alone is not enough — you must document the LEVEL OF CARE needed.
• Strong documentation for autism applications includes: ADOS or ADI-R assessment results, behavioral evaluations from a developmental pediatrician or psychologist, IEP from school showing functional limitations, daily logs of behavioral incidents requiring intervention, and a treating provider letter detailing the hours of supervision and behavioral support needed.
• APPLIED BEHAVIOR ANALYSIS (ABA): TennCare covers medically necessary ABA therapy for children with autism. Most plans cover 20-40 hours per week of ABA — far more than typical private insurance limits. Use this as a key benefit when explaining why TennCare matters for your family.
• DUAL DIAGNOSIS: Many autistic children also have co-occurring conditions (epilepsy, GI issues, anxiety, ADHD, sleep disorders). Document ALL of them. A 'just autism' application is weaker than 'autism + epilepsy + GI condition requiring specialized feeding.'
• MENTAL HEALTH/PSYCHIATRIC NEEDS: TennCare covers psychiatric medication management, individual therapy, family therapy, crisis intervention, and (in some cases) residential treatment. If your child has serious mental health needs alongside their disability, document them — it strengthens the LOC argument.
• TENNESSEE EARLY INTERVENTION SYSTEM (TEIS): For kids under 3 with developmental delays, TEIS provides free evaluations and services that can become Katie Beckett documentation later. Call 1-800-852-7157.
• PROVIDER FINDER: TennCare maintains a list of in-network behavioral health and autism providers. Call your Managed Care Organization (BlueCross BlueShield, Amerigroup, or UnitedHealthcare Community Plan) for the most current list.

Using Your Child's IEP as Application Evidence

• If your child receives special education services at school, their IEP (Individualized Education Plan) is one of the most powerful documents you can submit with a Katie Beckett application. Schools have already done a lot of the documentation TennCare needs.
• WHAT FROM THE IEP MATTERS: The Present Levels of Academic Achievement and Functional Performance section (often called 'Present Levels' or 'PLAAFP'). This is where evaluators describe in detail what your child can and cannot do.
• ALSO USEFUL FROM THE IEP: related services listed (OT, PT, speech, behavioral support, nursing services at school), accommodations and modifications needed, behavior intervention plan (BIP) if there is one, FAPE evaluation results, and any health plan attached.
• REQUEST A FULL COPY: under federal law (FERPA + IDEA), you can request a complete copy of your child's educational records including all evaluations, IEPs, BIPs, and progress reports. Ask the school's special education coordinator. They have 45 days to provide it.
• PAIR THE IEP WITH MEDICAL RECORDS: an IEP shows educational needs; medical records show health needs. Together they paint the full picture TennCare reviewers want to see.
• IF YOUR CHILD DOESN'T HAVE AN IEP YET: a 504 plan, an Individualized Family Service Plan (IFSP) from TEIS for kids under 3, or even a school nurse's daily care plan can serve as supporting evidence.
• REQUESTING AN IEP EVALUATION: if your child has medical needs that affect schooling but doesn't have an IEP, you can REQUEST an evaluation in writing. The school has 60 days to evaluate. Even if the IEP isn't ready before your Katie Beckett application, the request itself is documentation.

Real Family Case Studies (Anonymized)

• FAMILY 1 — Middle Tennessee, autism + epilepsy. Combined household income $112,000. Mom assumed they made too much for any TennCare program. Caidee pointed her to Katie Beckett — only the child's income counts. Application submitted with developmental pediatrician letter + IEP + neurologist epilepsy management plan. Approved in 71 days. Now covers $4,200/month in ABA therapy that private insurance capped at $800.
• FAMILY 2 — East Tennessee, ventilator-dependent child age 7. Initial application denied for 'insufficient level-of-care documentation.' Caidee Denied Guide template letter used. Pulmonologist re-submitted with hour-by-hour daily care log: 24-hour skilled nursing, suctioning every 3 hours, ventilator circuit changes, G-tube feeds every 4 hours. Appeal approved in 38 days. Family now has 16 hours/day of nursing care covered.
• FAMILY 3 — Memphis area, child with Down syndrome and complex heart condition. Family applied for SSI first (low income made them eligible) — auto-enrolled in TennCare. Then applied for ECF CHOICES for community supports and learned about the waiting list. 18-month wait, but child was enrolled at age 5 for services to start age 7. They use Katie Beckett documentation strategy as backup in case income rises.
• FAMILY 4 — West Tennessee, child with severe nonverbal autism + behavioral support needs. Application initially denied because reviewer said 'autism alone does not meet institutional LOC.' Family appealed with daily incident log showing 6+ aggressive episodes requiring two-person intervention, sleep disruption requiring caregiver supervision through the night, and elopement risk requiring locks. Approved on appeal. Now has 40 hours/week ABA + respite hours.
• FAMILY 5 — Knoxville, age-out situation. Child turning 18 with intellectual disability — family panicked about losing Katie Beckett. Applied for adult SSI 90 days before 18th birthday (rules differ for adults — only individual's income/assets count). Approved before transition. ECF CHOICES enrollment carried over. No coverage gap. Conservatorship paperwork filed at 17.5 to maintain medical decision-making.
• LESSONS: Every approved case shared THREE things — (1) specific medical/care documentation, not generalities, (2) a treating provider letter that directly addresses the eligibility criteria, (3) persistence through the appeals process when needed. Caidee gives you the framework. The documentation comes from your providers.

Key Contacts

Documents You Will Need

Nursing home Medicaid requires extensive financial documentation. Gather these items before applying:

• Photo ID (driver's license, state ID, or passport)
• Social Security card or number for everyone on the application
• Proof of Tennessee residency (utility bill, lease, or mail with your address)
• Proof of U.S. citizenship or immigration status (birth certificate, passport, or immigration documents)
• Proof of income for everyone in the household (pay stubs, tax return, Social Security statement, employer letter)
• Bank statements (checking and savings) for the past 30 days
• Child's birth certificate
• Child's Social Security card or number
• Medical records documenting the child's disability or medical condition
• Doctor's reports, specialist evaluations, and treatment plans
• Hospital discharge summaries (if applicable)
• Therapy records (physical, occupational, speech)
• List of current medications and treating physicians
• Any SSI or Social Security disability determination letters for the child
• Child's own income documentation (if any — most children have none)
• Current health insurance information for the child
• School IEP or 504 plan (if applicable)
• Power of Attorney or guardianship documents (if applicable)