Section 1200-13-14-.02 - ELIGIBILITY(1) Delineation of agency roles and responsibilities.(a) The Tennessee Department of Finance and Administration (F&A) is the lead State agency for the TennCare Program.(b) The Bureau of TennCare (Bureau) is the administrative unit within F&A with the responsibility for day-to-day operations of the TennCare Program. The Bureau is responsible for establishing policy and procedural requirements and criteria for TennCare. 1. With respect to the eligibility of children applying for TennCare as medically eligible persons, the Bureau is responsible for determining the presence of a qualifying medical condition under TennCare Standard.2. With respect to the eligibility of individuals applying for the TennCare CHOICES program, the Bureau is responsible for determining that the individual meets level of care eligibility criteria for the long-term care services or reimbursement requested. For enrollment into CHOICES Group 2, the Bureau is also responsible for determining the state's ability to provide appropriate Home and Community Based Services (HCBS) as determined by the availability of slots under the established enrollment target in accordance with Rule 1200-13-01-.05 and for confirming a determination by an Area Agency on Aging and Disability or TennCare Managed Care Organization that: (i) The individual is an adult aged sixty-five (65) or older, or an adult aged twenty-one (21) or older with physical disabilities; and(ii) Such individual can be safely and appropriately served in the community and at a cost that does not exceed the individual's cost neutrality cap pursuant to Rule 1200-13-01-.05.3. With respect to the eligibility of individuals applying for the ECF CHOICES program, the Bureau is responsible for determining that the individual meets all applicable eligibility and enrollment criteria, including target population, medical or level of care eligibility, categorical and financial eligibility, the state's ability to provide appropriate ECF HCBS (as defined in Rule 1200-13-01-.02) as determined by the availability of slots under the established enrollment target for each ECF CHOICES Group in accordance with Rule 1200-13-01-.31 and pursuant to intake and enrollment policies and processes described in 1200-13-01-.31 and in TennCare policies and protocols, and for confirming a determination by a TennCare Managed Care Organization that the individual can be safely and appropriately served in the community and at a cost that does not exceed the individual's expenditure cap pursuant to Rule 1200-13-01-.31.(c) The Tennessee Department of Human Services (DHS) is under contract with the Bureau to determine initial eligibility for TennCare Medicaid and TennCare Standard, as well as to redetermine, at regular intervals, whether eligibility should be continued. DHS is not responsible for making decisions about the presence of a qualifying medical condition for those applying as medically eligible persons under TennCare Standard.(d) The Social Security Administration determines eligibility for the Supplemental Security Income (SSI) Program. Tennessee residents determined eligible for SSI benefits are automatically eligible for and enrolled in TennCare Medicaid.(e) The Tennessee Department of Health (DOH) determines presumptive eligibility under TennCare Medicaid for pregnant women and for women diagnosed with breast or cervical cancer through administration of the Breast and Cervical Cancer Screening Program.(2) Delineation of TennCare enrollee's responsibilities.(a) It is the responsibility of each TennCare enrollee to report to the DHS any material change affecting any information given by the applicant/enrollee to DHS at the time of application or redetermination of his eligibility. This information includes, but is not limited to, changes in address, income, family size, employment, or access to insurance. The applicant/enrollee shall mail, or present in person, documentation of any such change to the DHS county office where the enrollee resides. This documentation must be presented within the time frame established by Tennessee Code Annotated § 71-5-110 for reporting changes.(b) It is the responsibility of each TennCare enrollee to report to his provider that he is a TennCare enrollee.(3) Technical and financial eligibility requirements for TennCare Standard. To be eligible for TennCare Standard, each individual must: (a) Not be eligible for Medicaid as determined by DHS.(b) Provide a statement from his employer, if employed, concerning the availability of group health insurance. (Access to insurance is not considered in determining eligibility in the Standard Spend Down category or any CHOICES or ECF CHOICES demonstration category.)(c) Be a U.S. citizen, lawfully admitted alien, or an alien permanently residing in the U.S. under color of law.(d) Be a Tennessee resident as described under federal and state law.(e) Present a Social Security number or proof of having applied for one, or assist the DHS caseworker in applying for a Social Security number, for each person applying for TennCare Standard.(f) Not be an inmate as defined in these rules.(g) Not be eligible for or have purchased other health insurance as defined at Rule 1200-13-14-.01, except for persons in the category of uninsured children under the age of nineteen (19) whose family income is below two hundred percent (200%) of poverty and who have been continuously enrolled in TennCare Standard since at least December 31, 2001. (Access to insurance is not considered in determining eligibility in the Standard Spend Down category or any CHOICES or ECF CHOICES demonstration category.)(h) Not be enrolled in, or eligible for participation in, Medicare. (Access to insurance is not considered in determining eligibility in the Standard Spend Down category or any CHOICES or ECF CHOICES demonstration category.)(4) General application requirements. (a) By applying for TennCare, an applicant grants permission and authorizes release of information to the Bureau, or its designee, to investigate any and all information provided, or any information not provided if it could affect eligibility, to determine TennCare eligibility; and if approved, what cost sharing, if any, may be required of the applicant as found in these rules. Information may be verified through, but not limited to, the following sources: 1. The United States Internal Revenue Service (IRS);2. State income tax records for Tennessee or any other state where income is earned;3. The Tennessee Department of Labor and Work Force Development, and other Employment Security offices within any state where the applicant may have received wages or been employed;5. Insurance companies; or,6. Any other governmental agency or public or private source of information where such information may impact an applicant's eligibility or cost sharing requirements for the TennCare Program.(b) By applying for TennCare, an applicant understands it is a felony offense, pursuant to Tennessee Code Annotated § 71-5-2601, to obtain TennCare coverage under false means or to help anyone get on TennCare under false means.(5) TennCare Standard: Uninsured and medically eligible children. (a) Coverage groups: 1. Group 1: Uninsured children under age nineteen (19) who are losing eligibility for Medicaid, who have family incomes below two hundred percent (200%) of poverty, and who do not have access to insurance.2. Group 2: Uninsured children under age nineteen (19) who are losing eligibility for Medicaid, who have family incomes that equal or exceed two hundred percent (200%) of poverty, who do not have access to insurance, and who have been determined medically eligible in accordance with these rules.3. Group 3: Uninsured children under age nineteen (19) who have been continuously enrolled in TennCare Standard since December 31, 2001, who have family incomes below two hundred percent (200%) of poverty, and who have not purchased insurance even if they have access to it. This is a "grandfathered" eligibility category. At such time as a person loses eligibility in this category, he will not be able to re-enroll in it.4. TennCare Standard is closed to new enrollment for children, except those children identified in (5)(a)1 and (5)(a)2 above.(b) Eligibility criteria: 1. The individual must be under nineteen (19) years of age.2. The individual must lack access to insurance, except those individuals in Group 3, defined in part (a)3 above. Individuals in Group 3 must not have purchased insurance that may be available to them.3. For persons in Groups 1 and 3 defined in parts (a)1 and 3 above, have family incomes that do not exceed two hundred percent (200%) of poverty.4. For persons in Group 2 defined in part (a)2 above, have been determined medically eligible in accordance with these rules.(c) Application procedures: 1. Uninsured children. An individual who is losing eligibility for TennCare Medicaid and who is under the age of nineteen (19) may be approved for TennCare Standard as a Medicaid "Rollover" Enrollee according to the following process:
(i) At least thirty (30) days prior to the expiration of their current eligibility period, the Bureau of TennCare will send the enrollee a Request for Information in accordance with rule 1200-13-13-.02(6)(b). The Request for Information will include a form to be completed with information needed to determine eligibility.(ii) Enrollees will be given thirty (30) days inclusive of mail time from the date of the Request for Information to return the completed form to DHS and to provide DHS with the necessary verifications to determine eligibility. When the individual returns a completed Request for Information form, he will first be screened for TennCare Medicaid eligibility. If the individual is no longer TennCare Medicaid eligible, he will be screened for eligibility as a Medicaid "Rollover" Enrollee in accordance with TennCare Standard eligibility criteria under rule 1200-13-14-.02.(iii) If DHS makes a determination that the enrollee is not eligible for any open Medicaid or Standard categories, the TennCare Bureau will send the enrol-lee a twenty (20) day advance Termination Notice.2. Medically eligible children. (i) Applicants have two (2) options for proving medical eligibility: (I) Option 1: A completed medical eligibility application and medical records to support any medical condition listed on the application, with a signed release for medical records in the event additional medical records are needed.(II) Option 2: Have a current CRG 1, 2, 3/TPG 2 assessment on file with the Bureau.(ii) If a Medicaid enrollee under age nineteen (19) whose Medicaid eligibility is ending is determined to otherwise meet technical eligibility requirements for TennCare Standard, but is not eligible as uninsured because his income is above two hundred percent (200%) of poverty, he will be sent a letter denying TennCare Standard coverage as uninsured and notifying the enrollee that he may qualify as medically eligible. The enrollee will have forty (40) days (inclusive of mail time) to appeal the denial of TennCare Standard as uninsured.(iii) When DHS makes the determination that the enrollee does not qualify for TennCare Standard as uninsured, TennCare will be notified and will send the enrollee a medical eligibility packet with an explanation regarding how to apply for TennCare Standard as a medically eligible person. The enrollee will have sixty (60) days from the date of the letter (inclusive of mail time) to submit his medical eligibility packet. If the individual is determined to qualify as medically eligible, coverage will be provided throughout the eligibility determination period and will continue with no break.(iv) The required medical eligibility application information must be returned to the address specified within sixty (60) days from the date of the letter included in the packet. A medical eligibility form and documentation received after that time will not be processed as it exceeds the timely filing requirement. Packets which are not completed by the sixtieth (60th) day will be denied with a notice of appeal rights and the "good cause" reasons for not completing the process timely, which include: (I) The applicant was sick.(II) A member of the applicant's immediate family was very sick.(III) The applicant had a family emergency or tragedy.(IV) The applicant could not get the medical records he needed from a provider. It was not his fault.(V) The applicant asked for help because he had a disability. Neither the Bureau nor DHS gave the help the applicant needed.(VI) The applicant asked for help because he does not speak English. Neither the Bureau nor DHS gave the help the applicant needed.(v) The Bureau of TennCare will review the completed medical eligibility packet. Evaluation of completed packets will be made within thirty (30) days of receipt from the applicant. Medical Reviewers will assess the records submitted against TennCare medical insurance underwriting guidelines. Applicants who are not determined to be medically eligible by the Bureau will not be eligible for TennCare Standard. They will receive a termination notice which contains appeal rights including the right to appeal within forty (40) days from the receipt of the termination notice. Appeals received by the Bureau after forty (40) days will be considered untimely and will not be forwarded to hearing.(vi) Applicants deemed medically eligible by the Bureau of TennCare will be approved for TennCare Standard. The Bureau will send the applicant an approval notice of coverage. The eligibility period for medically eligible individuals is twelve (12) months. At the end of twelve (12) months, the enrol-lee must complete the redetermination/reapplication process.(vii) The effective date of coverage will be the date of application.(6) TennCare Standard: Standard Spend Down (SSD) Program.(a) Coverage group. Non pregnant adults, age 21 and older, who have been determined to meet criteria patterned after the Medically Needy requirements, as outlined in DHS rule 1240-03-02-.03 and who are age 65 or older, blind, disabled, or caretaker relatives of Medicaid-eligible children.
(b) Eligibility criteria: 1. Must be age twenty-one (21) or older.3. Must meet one of the following criteria:(i) Be sixty-five (65) years of age or older; or(ii) Be blind, as defined in DHS rule 1240-03-03-.02; or(iii) Be disabled, as defined in DHS rule 1240-03-03-.02; or(iv) Be a caretaker relative, as defined at T.C.A. § 71-3-153.4. Must meet the financial eligibility criteria, including income and resource limitations that apply to Medically Needy pregnant women and children eligible under the State plan. These criteria are found at DHS rules 1240-03-03-.05 and 1240-03-03-.06.5. Must be enrolled in accordance with an enrollment target of 100,000 Tennessee residents who have been determined to be eligible for the Standard Spend Down (SSD) Program; with a maximum of 105,000 persons to be enrolled at any given time.(c) Application procedures: 1. SSD categories. (i) Category 1. Individuals who are not eligible for Medicaid at the time the SSD program is implemented and who meet the criteria for the new SSD program. Category 1 applicants will be processed for eligibility only through a single toll-free telephone point of entry (the Call-in Line) initiated in periods of open enrollment. In each such period, the State will determine a specified number of calls that it will accept through the Call-in Line based on the number of Category 1 applications that the State estimates it can process within Federal timeliness standards. The number of calls to be accepted in these periods will be based on the number of remaining slots available under the enrollment target of 100,000 persons. The State will not accept or track calls received outside of these periods.
(ii) Category 2. Individuals in the Transition Group who, at the time the SSD program is implemented, are eligible for Medicaid in a non-pregnant adult Medically Needy category, who have completed their twelve (12) months of Medicaid eligibility, have been found to be ineligible for any other Medicaid category, and have been determined to meet the criteria of the SSD program. For Category 2 individuals, the State will determine their SSD eligibility on a rolling basis in conjunction with their termination from Medicaid, and shall reserve sufficient slots within the enrollment target to ensure that all such persons who are eligible may be accepted in the SSD category.
Termination procedures for Category 2 individuals who are not eligible for Medicaid or for SSD will be conducted in accordance with those outlined in Paragraph (7)(b) of this rule.
Upon implementation of the SSD program, the State will review all Category 2 individuals for either eligibility in a new Medicaid category or approval as a Standard Spend Down eligible. After the review of all Category 2 individuals is complete and it is determined how many additional enrollees can be added to the SSD program without exceeding the enrollment cap, the State will begin enrolling persons in Category 1.
2. Initial application period for Category 1. The State will establish an initial target enrollment figure based on its determination of the minimum number of applications the State estimates it can process in a timely manner in accordance with Federal standards. The State's decision to open or close enrollment is a policy decision that is within the State's discretion and the State is not required to provide fair hearings for challenges to these decisions. A toll-free Call-in Line to receive requests for applications will be established and requests will be processed as follows:
(i) Callers to the Call-in Line will be asked for basic demographic information and will be assigned a unique identifier.(ii) A match will be conducted to verify that callers are not already eligible in a TennCare Medicaid category. Those callers who are already eligible in a TennCare Medicaid category will be sent letters advising them that they currently have benefits and need not apply for Standard Spend Down.(iii) For those callers who are not Medicaid eligible, the State will send a written application form, accompanied by a letter advising the individual of the requirement to complete, sign, and return the application within thirty (30) days.(iv) Completed, signed applications received by the State by the thirty (30)-day deadline will be evaluated for Medicaid eligibility and SSD eligibility. Applications received after the deadline will not be reviewed for SSD eligibility but will be processed for Medicaid eligibility. There will be no "good cause" exception to the written application deadline set by the State. If the State does not receive an application by the deadline, the State will send the individual a letter advising him that since no application was received, the State will not make an eligibility determination for him, but the individual is free to apply for SSD during any subsequent open application period and to apply for Medicaid at any time. No hearings will be granted to individuals concerning this process who have not timely submitted signed applications unless the individual alleges a valid factual dispute that he did submit a signed, written application within the deadline.(v) Since all SSD applications received during an open application period will be processed and either approved or denied, there is no requirement for the State to maintain a "waiting list" of potential SSD applicants. No applications submitted in one open application period will be carried forward to future open application periods. The State will determine SSD eligibility within the timeframes specified by Federal regulations at 42 CFR § 435.911; such time frames will begin on the date a signed written application is received by the State.3. New application periods after the SSD enrollment target has been reached. Once the State has reached its targeted enrollment of 100,000 persons, new application periods will be scheduled when the number of approved eligibles in the SSD program drops to ninety percent (90%) of target enrollment, or 90,000 persons. Any subsequent application periods will remain open until a pre-determined number of calls to the Call-in Line have been received. The number of calls to be received will be based on the State's determination of the minimum number of applications necessary to fill open slots in the program and the number of applications the state estimates it can process in a timely manner in accordance with Federal standards. The State's decision to open or close enrollment is a policy decision that is within the State's discretion and the State is not required to provide fair hearings for challenges to these decisions.
4. Period of eligibility. All enrollees in the SSD demonstration category will have an eligibility period of twelve (12) months from the effective date of eligibility. At the end of the twelve (12)-month period each enrollee must have his eligibility redetermined in order to establish SSD or Medicaid eligibility. The duration of the eligibility period for SSD eligibility is the same as that used for Medically Needy pregnant women and children in TennCare Medicaid.
5. Effective date of eligibility for SSD enrollees. The effective date of SSD eligibility for an individual whose application for SSD eligibility is initiated through the Call-in Line and who submits a timely signed application will be the later of:
(i) The date his call was received by the Call-in Line; or(ii) The date spend-down is met (which must be no later than the end of the one (1)-month budget period - in this case, the end of the month of the original call to the Call-in Line).(iii) The effective date of SSD eligibility for an individual whose eligibility is being redetermined is the application date.(iv) For Category 2 individuals the effective date will be determined in accordance with DHS rule 1240-03-02-.04.(7) TennCare Standard: CHOICES 217-Like Group (a) Coverage group. Individuals age sixty-five (65) and older and adults age twenty-one (21) and older with physical disabilities who meet the Nursing Facility (NF) level of care criteria, who could have been eligible for HCBS under 42 C.F.R. § 435.217 had the state continued its 1915(c) HCBS Waiver for persons who are elderly and/or physically disabled, and who need and are receiving HCBS as an alternative to Nursing Facility (NF) care. This group exists only in the Grand Divisions of the state where the CHOICES program has been implemented, and participation is subject to the enrollment target for CHOICES Group 2.(b) Eligibility criteria:1. Must be aged sixty-five (65) and older or aged twenty-one (21) and older with physical disabilities as defined in Rule 1200-13-01-.02;2. Must meet the Nursing Facility level of care requirements;3. Must have a current determination by an Area Agency on Aging and Disability or the TennCare MCO to which the individual is assigned, that he is able to be safely and appropriately served in the community and within his individual cost neutrality cap as defined in Rule 1200-13-01-.05;4. May be enrolled in accordance with requirements pertaining to the enrollment target for CHOICES Group 2, as described in Rule 1200-13-01-.05;5. Will be enrolled and begin receiving Home and Community Based Services (HCBS) upon determination of financial eligibility by DHS and continue to receive HCBS as a CHOICES Group 2 participant. Qualifying for enrollment into CHOICES Group 2 (HCBS) is not sufficient to establish eligibility in the CHOICES 217-Like Group if the person will not actually be enrolled and receiving HCBS; and6. Would be eligible in the same manner as specified under 42 C.F.R. § 435.217, 435.236, and 435.726 and section 1924 of the Social Security Act (42 U.S.C.A. § 1396r-d), if the Home and Community Based Services (HCBS) were provided under a section 1915(c) waiver.(c) Application procedures 1. To be eligible for the CHOICES 217-Like Group, each individual must meet all technical and financial requirements applicable to this category as described in DHS Rule Chapter 1240-03-03.2. The effective date of eligibility in the CHOICES 217-Like Group shall be the date the application is approved by DHS. In no instance shall the effective date of eligibility precede the date the application was filed with DHS.(8) TennCare Standard: ECF CHOICES 217-Like Group.(a) Coverage group. Individuals with I/DD of all ages who meet the NF LOC criteria who need and are receiving HCBS, and who would be eligible in the same manner as specified under Section 1902(a) of the Social Security Act and 42 C.F.R. § 435.217, if the HCBS were provided under a Section 1915(c) waiver. Enrollment in this group shall be subject to the enrollment targets established for each applicable ECF CHOICES benefit group. An Applicant may qualify in the ECF CHOICES 217-Like Group only when there is an available slot for enrollment into an ECF CHOICES benefit group for which the Applicant meets all eligibility and enrollment criteria, including prioritization criteria for enrollment into ECF CHOICES as established in these Rules, and when the Applicant upon approval of financial eligibility, will be enrolled by TennCare into such ECF CHOICES group.(b) Eligibility criteria: 1. Must have an intellectual or developmental disability as defined in Rule 1200-13-01-.02;2. Must meet the Nursing Facility level of care requirements;3. Must have a current determination by the TennCare MCO to which the individual is assigned, that he is able to be safely and appropriately served in the community and within his expenditure cap as defined in Rule 1200-13-01-.31, except in instances where the Applicant is not eligible for TennCare at the time of ECF CHOICES application, in which case, such determination shall be made by the MCO upon enrollment into ECF CHOICES;4. May be enrolled in accordance with requirements pertaining to the enrollment target for each ECF CHOICES Group, including prioritization criteria for enrollment into ECF CHOICES, as described in Rule 1200-13-01-.31;5. Will be enrolled and begin receiving Home and Community Based Services (HCBS) upon determination of financial eligibility by TennCare and continue to receive HCBS as an ECF CHOICES participant. Qualifying for enrollment into ECF CHOICES is not sufficient to establish eligibility in the ECF CHOICES 217-Like Group if the person will not actually be enrolled and receiving HCBS; and6. Would be eligible in the same manner as specified under Section 1902(a) of the Social Security Act and 42 C.F.R. § 435.217, if the Home and Community Based Services (HCBS) were provided under a section 1915(c) waiver.(c) Application procedures: 1. To be eligible for the ECF CHOICES 217-Like Group, each individual must meet all technical and financial requirements applicable to this category as described in Rule Chapter 1200-13-20.2. The effective date of eligibility in the ECF CHOICES 217-Like Group shall be the date the application is approved by TennCare. In no instance shall the effective date of eligibility precede the date the application was filed with TennCare.(9) TennCare Standard: Interim ECF CHOICES At-Risk Group.(a) Coverage group. Individuals who have an intellectual or developmental disability as defined in Rule 1200-13-01.-02 who meet the financial eligibility standards for the ECF CHOICES 217-Like Group; do not meet the Nursing Facility (NF) level of care criteria, but in the absence of ECF CHOICES HCBS, are At Risk for Institutionalization as defined in Rule 1200-13-01-.02; and who need and are receiving ECF CHOICES HCBS. The Interim ECF CHOICES At-Risk Demonstration Group will open to new enrollment only until such time that the Employment and Community First CHOICES At-Risk Demonstration Group (with income up to one hundred and fifty percent (150%) of the FPL) and the Employment and Community First CHOICES Working Disabled Demonstration Groups can be established. Persons enrolled in the Interim ECF CHOICES At-Risk Demonstration Group as of the date new enrollment into the group closes may continue to qualify in the group as long as they continue to meet nursing facility financial eligibility standards and are At-Risk for Institutionalization as defined in Rule 1200-13-01-.02, and remain continuously eligible and enrolled in the Interim ECF CHOICES At-Risk Demonstration Group. Enrollment in this group shall be subject to the enrollment targets established for each applicable ECF CHOICES benefit group. An Applicant may qualify in the Interim ECF CHOICES At-Risk Group only when there is an available slot for enrollment into an ECF CHOICES benefit group for which the Applicant meets all eligibility and enrollment criteria, including prioritization criteria for enrollment into ECF CHOICES as established in Rule 1200-13-01-.31, and when the Applicant, upon approval of financial eligibility, will be enrolled by TennCare into such ECF CHOICES group.(b) Eligibility criteria: 1. Must have an intellectual or developmental disability as defined in Rule 1200-13-01-.02;2. Must meet the financial eligibility standards for the ECF CHOICES 217-Like Group;3. Do not meet the Nursing Facility level of care, but in the absence of ECF CHOICES HCBS, are At Risk for Institutionalization as defined in Rule 1200-13-01-.02;4. Must have a current determination by the TennCare MCO to which the individual is assigned, that he is able to be safely and appropriately served in the community and within his expenditure cap as defined in Rule 1200-13-01-.31, except in instances where the Applicant is not eligible for TennCare at the time of ECF CHOICES application, in which case, such determination shall be made by the MCO upon enrollment into ECF CHOICES; and5. May be enrolled in accordance with requirements pertaining to the enrollment target for each ECF CHOICES Group, including prioritization criteria for enrollment into ECF CHOICES as described in Rule 1200-13-01-.31; and6. Will be enrolled and begin receiving Home and Community Based Services (HCBS) upon determination of financial eligibility by TennCare and continue to receive HCBS as an ECF CHOICES participant. Qualifying for enrollment into ECF CHOICES is not sufficient to establish eligibility in the Interim ECF CHOICES At-Risk Group if the person will not actually be enrolled and receiving ECF CHOICES HCBS.(c) Application procedures: 1. To be eligible for the Interim ECF CHOICES At-Risk Group, each individual must meet all technical and financial requirements applicable to this category as described in Rule Chapter 1200-13-20.2. The effective date of eligibility in the Interim ECF CHOICES At-Risk Group shall be the date the application is approved by TennCare. In no instance shall the effective date of eligibility precede the date the application was filed with TennCare.(10) Redetermination of eligibility in TennCare Standard (other than CHOICES 217-Like Group, ECF CHOICES 217-Like Group, and Interim ECF CHOICES At-Risk Group). (a) All enrollees must reapply and have their TennCare coverage redetermined based on the approved policies and procedures in effect at the time of their next scheduled rede-termination/reapplication process. TennCare Standard enrollees shall have their eligibility redetermined in accordance with the following process:1. Ex Parte Review. DHS will conduct an ex parte review of eligibility for open Medicaid and Standard categories for all TennCare Standard enrollees due for redetermination. Such ex parte reviews shall be conducted in accordance with federal requirements set forth by CMS in the Special Terms and Conditions of the TennCare demonstration project.
2. Request for Information. (i) At least thirty (30) days prior to the expiration of their current eligibility period, the Bureau of TennCare will send a Request for Information to all TennCare Standard enrollees. The Request for Information will include a form to be completed with the information needed to determine eligibility for open Medicaid and Standard categories, as well as a list of the types of proof needed to verify certain information.(ii) Enrollees will be given thirty (30) days inclusive of mail time from the date of the Request for Information to return the completed from to DHS and provide DHS with the necessary verifications to determine eligibility for open Medicaid and Standard categories.(iii) Enrollees with a health problem, mental health problem, learning problem, or a disability will be given the opportunity to request assistance in responding to the Request for Information. Enrollees with Limited English Proficiency will have the opportunity to request translation assistance for responding to the Request for Information.(iv) Enrollees will be given an opportunity until the date of termination to request one (1) extension for good cause of the thirty (30) day time frame for responding to the Request for Information. The good cause extension is intended to allow a limited avenue for possible relief for certain enrollees who face significant unforeseen circumstances, or who, as a result of a health problem, mental health problem, learning problem, disability, or limited English proficiency, are unable to respond timely. The good cause exception does not confer entitlement upon enrollees and the application of this exception will be within the discretion of DHS. Only one (1) thirty (30) day good cause extension can be granted to each enrollee. Good cause is determined by DHS eligibility staff. Good cause is not requested nor determined through filing an appeal. Requests for an extension of the thirty (30) day time frame to respond to the Request for Information must be initiated by the enrollee. However, the enrollee may receive assistance in initiating such request. DHS will not accept a request for extension of the thirty (30) day time frame submitted by a family member, advocate, provider, or CMHC, acting on the enrollee's behalf without the involvement and knowledge of the enrollee, for example, to allow time for such entity to locate the enrollee if his whereabouts are unknown. All such requests for good cause extension must be made prior to termination of TennCare eligibility. A good cause extension will be granted if DHS determines that a health problem, mental health problem, learning problem, disability, or limited English proficiency prevented an enrollee from understanding or responding timely to the Request for Information. Except in the aforementioned circumstances, a good cause extension will only be granted if such request is submitted in writing to DHS prior to termination of TennCare eligibility and DHS determines that serious personal circumstances such as illness or death prevent an enrollee from responding to the Request for Information for an extended period of time. Proof of the serious personal circumstances is required with the submission of the written request in order for a good cause extension to be granted. Good cause extensions will be granted at the sole discretion of DHS and if granted shall provide the enrol-lee with an additional thirty (30) days inclusive of mail time from the date of DHS's decision to grant the good cause extension. DHS will send the enrol-lee a letter granting or denying the request for good cause extension. DHS's decisions with respect to good cause extensions shall not be appealable.(v) If an enrollee provides some but not all of the necessary information to DHS to determine his eligibility for open Medicaid categories or continuation in TennCare Standard during the thirty (30) day period following the Request for Information, DHS will send the enrollee a Verification Request. The Verification Request will provide the enrollee ten (10) days inclusive of mail time to submit any missing information as identified in the Verification Request. Enrollees will not have the opportunity to request an extension for good cause of the ten (10) day time frame for responding to the Verification Request.(vi) Enrollees who respond to the Request for Information within the thirty (30) day period or within any extension of such period granted by DHS shall retain their eligibility for TennCare Standard (subject to any changes in covered services generally applicable to enrollees in their TennCare Standard category) while DHS reviews their eligibility.(vii) DHS shall review all information and verifications provided within the requisite time period by an enrollee pursuant to the Request for Information and/or Verification Request to determine whether the enrollee is eligible for any open Medicaid categories or whether the enrollee is eligible to remain in TennCare Standard. If DHS makes a determination that the enrollee is eligible for an open Medicaid category or to remain in TennCare Standard, DHS will so notify the enrollee and the enrollee will be enrolled in the appropriate TennCare category. When the enrollee is enrolled in TennCare Medicaid, his TennCare Standard eligibility shall be terminated without additional notice. If DHS makes a determination that the enrollee is not eligible for any TennCare category or if the enrollee does not respond to the Request for Information within the requisite thirty (30) day time frame or any extension of such period granted by DHS, the TennCare Bureau will send the enrollee a twenty- (20) day advance Termination Notice.(viii) DHS shall, pursuant to the rules, policies, and procedures of DHS and the Bureau of TennCare applicable to new applicants for TennCare coverage, review all information and verifications provided by an enrollee after the thirty (30) day period following the Request for Information or after any extension of such period granted by DHS, but the enrollee shall not be entitled to retain eligibility for TennCare Standard pending this review. If the individual is subsequently determined to be eligible for an open Medicaid category, he shall be granted retroactive coverage to the date of application, or in the case of spend down eligibility for Medically Needy pregnant women and children, to the latter of (a) the date of his application, or (b) the date spend down eligibility is met as defined in Department of Human Services rule 1240-03-02-.04.3. Notice of termination. (i) The TennCare Bureau will send Termination Notices to all TennCare Standard enrollees being terminated who are not determined to be eligible for open Medicaid or Standard categories pursuant to the Ex Parte Review or Request for Information processes described in this subparagraph.(ii) Termination Notices will be sent twenty (20) days in advance of the date upon which the coverage will be terminated.(iii) Termination Notices will provide enrollees with forty (40) days from the date of the notice to appeal valid factual disputes related to the disenrollment and will inform enrollees how they may request a hearing.(iv) Enrollees with a health problem, mental health problem, learning problem, or a disability will be given the opportunity to request additional assistance for their appeal. Enrollees with Limited English Proficiency will have the opportunity to request translation assistance for their appeal.(v) Enrollees will not have the opportunity to request an extension for good cause of the forty (40) day time frame in which to request a hearing.(b) A TennCare Standard enrollee shall be required to have his eligibility redetermined for TennCare Standard prior to the expiration date of the current period of coverage as instructed by the DHS. The enrollee's continued eligibility for TennCare Standard is determined as of the date of the redetermination appointment or a later date if the enrollee does not submit all required documentation at the initial appointment. (The later date must be before the date of expiration of coverage.)(c) Information to be recertified includes changes in address, income, employment, family size, and access to health insurance (access to insurance is not considered in determining eligibility in the Standard Spend Down category). Redetermination appointments must be scheduled and kept regardless of whether any changes have occurred. It is the responsibility of the enrollee to furnish all information requested. The notice reminding the enrollee that he must have his eligibility redetermined will inform the enrollee of the documentation to be brought to the appointment.(d) The enrollee must complete the entire redetermination process prior to the expiration date of his coverage. Failure to do so will result in coverage lapsing as of the expiration date. The enrollee will not be permitted to appeal the expiration of his coverage in this situation. However, he may appeal on the grounds that: 1. He did, in fact, complete the redetermination process but an administrative error on the part of the State resulted in his coverage expiring; or2. He was prevented from completing the redetermination process by specific acts or omissions of state employees. However, this ground for appeal does not include challenges to relevant TennCare rules, policies or timeframes. The individual will receive a notice of the expiration of his coverage and his right to appeal, as set out above, within ten (10) days. There will be no continuation or reinstatement of coverage pending appeal.
(e) Enrollees approved for TennCare Standard as medically eligible persons may also be required to submit proof of continued medical eligibility. Documentation shall be that as required elsewhere in these rules. If as a result of the redetermination appointment it is determined that any enrollee no longer meets the technical eligibility requirements set out at rule 1200-13-14-.02, the enrollee will be disenrolled from TennCare Standard. The enrollee will be sent a notice of termination, and the enrollee has the right to appeal the decision within forty (40) calendar days of the receipt of the letter informing the enrollee of the loss of eligibility. The enrollee's right to appeal is set out at rule 1200-13-14-.12.(11) Redetermination of eligibility in the CHOICES 217-Like Group. An enrollee who qualifies for TennCare through DHS shall have his TennCare eligibility redetermined by DHS as required by the appropriate category of medical assistance. Prior to termination, eligibility will be reviewed in accordance with the following process:
(a) At least thirty (30) days prior to the expiration of his current eligibility period, the Bureau of TennCare will send a Request for Information to the enrollee. The Request for Information will include a form to be completed with information needed to verify continued eligibility in the CHOICES 217-Like Group.(b) Enrollees will be given thirty (30) days inclusive of mail time from the date of the Request for Information to return the completed form to DHS and to provide DHS with the necessary verifications to determine continued eligibility for the CHOICES 217-Like Group.(c) Enrollees with a health problem, mental health problem, learning problem or a disability will be given the opportunity to request assistance in responding to the Request for Information. Enrollees with Limited English Proficiency will have the opportunity to request translation assistance for responding to the Request for Information.(d) If an enrollee provides some but not all of the necessary information to DHS to verify his continued eligibility for the CHOICES 217-Like Group during the thirty (30) day period following the Request for Information, DHS will send the enrollee a Verification Request. The Verification Request will provide the enrollee with ten (10) days inclusive of mail time to submit any missing information as identified in the Verification Request.(e) Enrollees who respond to the Request for Information within the thirty (30) day period shall retain their eligibility for TennCare (subject to any changes in covered services generally applicable to enrollees in their eligibility category) while DHS reviews their eligibility in the CHOICES 217-Like Group.(f) Enrollees who respond to the Request for Information or the Verification Request after the requisite time period specified in those notices but before the date of termination shall retain their eligibility for TennCare while DHS reviews their eligibility in the CHOICES 217-Like Group. If DHS determines that the enrollee remains eligible for his current CHOICES 217-Like category, the enrollee will remain enrolled in such category. If DHS makes a determination that the enrollee is not eligible for continued enrollment in the CHOICES 217-Like Group, the TennCare Bureau will send the enrollee a twenty (20) day advance Termination Notice.(g) Individuals may provide the information and verifications specified in the Request for Information after termination of eligibility. DHS shall review all such information pursuant to the rules, policies and procedures of DHS and the Bureau of TennCare applicable to new applicants for TennCare coverage.(12) Losing eligibility for TennCare Standard. (a) Eligibility for TennCare Standard shall cease when it has been determined that the enrollee, as the result of one of the following events, no longer meets the criteria for the program. Eligibility for TennCare Standard shall end if: 1. The enrollee becomes eligible for participation in a group health insurance plan, as defined in this Chapter, either directly or indirectly through a family member. (Access to insurance is not considered in determining eligibility in the Standard Spend Down category or any CHOICES or ECF CHOICES demonstration category);2. The enrollee becomes eligible for Medicare. (Access to insurance is not considered in determining eligibility in the Standard Spend Down category or any CHOICES or ECF CHOICES demonstration category);3. The enrollee is determined eligible for Medicaid (this does not apply to the CHOICES 1 and 2 Carryover Group or the PACE Carryover Group; does not apply to the CHOICES 217-Like Group, CHOICES At-Risk Demonstration Group or any ECF CHOICES demonstration category unless the enrollee begins receiving SSI);4. The enrollee purchases an individual health insurance plan as defined by this Chapter. (Access to insurance is not considered in determining eligibility in the Standard Spend Down category or any CHOICES or ECF CHOICES demonstration category);5. The enrollee fails to comply with TennCare Program requirements, subject to federal and state laws and regulations;7. It is determined that any of the technical eligibility requirements found in this Rule are no longer met;8. The enrollee has failed to respond to a redetermination process requirement, as described in this Rule, to assure that the enrollee and other family members, as appropriate, remain eligible for TennCare Standard;9. The enrollee sends a voluntary written request for termination of eligibility for TennCare Standard to the DHS county office in the county in which he resides;10. The enrollee no longer qualifies as a resident of Tennessee under federal and state law;11. The enrollee fails to complete the redetermination process within the timeframes specified within this Rule;12. The enrollee becomes incarcerated as an inmate;13. The Bureau determines that the enrollee does not actually have the medical condition(s) which rendered him "medically eligible" for TennCare Standard;14. The enrollee attains the age of nineteen (19) and has not been determined eligible in an open Medicaid category; or15. An enrollee in any CHOICES or ECF CHOICES demonstration category no longer satisfies one or more of the eligibility criteria applicable for the category as specified in this Rule.(b) TennCare Standard enrollees who are disenrolled from TennCare pursuant to this Rule shall be allowed to re-enroll in the TennCare program at any time if they become TennCare Medicaid-eligible or eligible in a CHOICES or ECF CHOICES demonstration category for which enrollment remains open, in accordance with this Rule, and shall not be required to pay arrearages as a condition of re-enrollment. However, nothing in this provision shall eliminate the enrollee's responsibility for unpaid premiums or copayments incurred under any previous period of eligibility.Tenn. Comp. R. & Regs. 1200-13-14-.02
Public necessity rule filed July 1, 2002; effective through December 13, 2002. Original rule filed September 30, 2002; to be effective December 14, 2002; however, on December 9, 2002, the House Government Operations Committee of the General Assembly stayed rule 1200-13-14-.02; new effective date February 12, 2003. Emergency rule filed December 13, 2002; effective through May 27, 2003. Public necessity rules filed April 29, 2005; effective through October 11, 2005. Public necessity rules filed June 3, 2005; effective through November 15, 2005. Amendments filed July 28, 2005; effective October 11, 2005. Amendments filed September 1, 2005; effective November 15, 2005. Amendment filed January 26, 2007; effective April 11, 2007. Public necessity rule filed February 8, 2008; effective through July 22, 2008. Repeal and new rule filed May 7, 2008; effective July 21, 2008. Emergency rule filed March 1, 2010; effective through August 28, 2010. Amendment filed May 27, 2010; effective August 25, 2010. Amendment filed October 4, 2012; effective January 2, 2013. Amendments filed September 26, 2013; effective December 25, 2013. Emergency rules filed July 1, 2016; effective through December 28, 2016. Amendments filed September 30, 2016; effective 12/29/2016.Authority: T.C.A. §§ 4-5-202, 4-5-208, 4-5-209, 71-5-105, 71-5-109, and Executive Order No. 23.