Home › TEFRA and FOA Medicaid Buy-in Programs: An Educational Worksheet from the Catalyst Center

TEFRA and FOA Medicaid Buy-in Programs: An Educational Worksheet from the Catalyst Center

The ACA addresses the need for affordable health insurance and improves consumer protections

One of the objectives of the Affordable Care Act (ACA) is to “make coverage more secure for those who have insurance, and extend affordable coverage to the uninsured.”1 The creation of Health Insurance Marketplaces, the essential health benefits requirement for new individual policies and small group health plans sold in and out of the marketplaces, and the expansion of Medicaid (mandatory for 6- to 19-year olds; optional for adults) created new pathways to affordable coverage.

The ACA also includes consumer protections that are particularly important for children with special health care needs (CSHCN) who have private health insurance. The majority of private insurance companies can no longer:

  • Deny coverage to individuals with pre-existing conditions*
  • Impose annual or lifetime benefit caps*
  • Drop coverage because of a mistake or inadvertent omission on an application
  • Refuse to renew a policy based on health status§

*Grandfathered2 individual health plans are exempt
§ Grandfathered individual and group plans are exempt
Note: As reported in the 2014 Employer Health Benefits Survey, in the last two years the percent of workers covered by “grandfathered” plans has decreased from 48% to 26%.3

Despite protections, the ACA does not universally address the issue of inadequate health insurance for CSHCN

Nationally, 34.3% of families raising CSHCN who have health insurance report their insurance is inadequate.4 It does not pay for all the services their children need, does not provide access to the providers their children need, and/or the out-of-pocket expenses are not reasonable. In addition, while the majority of insurers can no longer cap the annual or lifetime dollar amount of coverage they provide, health plans can still limit the amount, scope, and duration of specific benefits. For example, health plans can still impose limits on the number of habilitative or mental health visits, which may limit services for a child with a chronic health care need or disability.


Medicaid, with its federally mandated Early and Periodic Screening, Diagnostic and Treatment (EPSDT)5 benefit, provides comprehensive medical, mental, developmental, dental,and specialty services with little or no cost sharing for all eligible children. EPSDT is particularly beneficial for children with disabilities. But, access to Medicaid is limited because of family income restrictions.

Options for expanding access to Medicaid for children with disabilities

States have options for providing alternate pathways to Medicaid for children with disabilities whose family income is higher than the state’s eligibility limit. TEFRA and the Family Opportunity Act (FOA) Medicaid Buy-in Program are two specific programs that can help families whose private insurance doesn’t pay for everything their child needs. These programs provide supplemental Medicaid coverage for co-pays, deductibles, and uncovered services for a child with a disability.

New educational worksheet helps you make the case for expanded Medicaid access for children with disabilities in your state

The Catalyst Center has created a TEFRA and FOA Medicaid Buy-in Educational Worksheet that you can use to learn about the similarities and differences between these two programs. Using the attached instructions, you can fill out the worksheet with data on the insurance status of families in your state. We hope this tool will be a good introduction to using data to make the case for improving coverage for children and youth with disabilities.

1http://www.hhs.gov/strategic-plan/goal1.html
2A grandfathered plan is a job-based or individual plan that existed before March 23, 2010, the day the ACA was signed. As long as it does not substantially increase consumer costs or cut benefits, the plan is exempt from some provisions of the ACA. Learn more at https://www.healthcare.gov/what-if-i-have-a-grandfathered-health-plan/
3http://kff.org/private-insurance/report/2014-employer-health-benefits-survey/
4http://www.childhealthdata.org/browse/survey/results?q=1630&r=1
5http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-and-Periodic-Screening-Diagnostic-and-Treatment.html

Learn More

TEFRA & TEFRA Look-Alike Programs

The TEFRA Medicaid State Plan Option and Katie Beckett Waiver for Children:
Making It Possible to Care for Children with Significant Disabilities at Home

Share this