Section 1240-03-02-.04 - ENROLLMENT FOR STANDARD SPEND DOWN INDIVIDUALS(1) Transition Group enrollees not found eligible in an open category of Medicaid, will be selected for Standard Spend Down processing through the Request for Information (RFI) process. The TennCare waiver gives the State the authority to establish an enrollment cap and to limit open enrollment periods to the number of individuals who can be admitted under the cap.(2) Categories for enrollment in the Standard Spend Down (SSD) program are as follows:(a) Category 1. People who are not eligible for Medicaid at the time the SSD program is implemented and who meet the criteria for the new SSD program. (Bureau of TennCare will announce open enrollment for SSD).(b) Category 2. People 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, who have been found to be ineligible for any other Medicaid category, and who have been determined to meet the criteria of the SSD program.(3) Applicants in the above categories will be enrolled as follows: (a) Category 1 (applicants who will be allowed to apply when announced by the Bureau of TennCare) will be enrolled only through a single toll-free telephone point of entry (the Call-in Line) initiated in periods of acceptance of new applications. In each open enrollment 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, together with projected pending applications from Category 2, the State estimates it can process within Federal timeliness standards. The number of calls to be accepted in open enrollment periods will also be based on the number of remaining slots available under the enrollment target and the number of slots necessary to reserve for non-pregnant Medically Needy adults in Category 2. The State will not accept or track calls received outside of open enrollment periods.(b) 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. 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.
(4) New open enrollment periods as announced by the Bureau of TennCare. Once the State has reached its targeted enrollment, new open enrollment periods will be scheduled when enrollment in the SSD program drops to ninety percent (90%) of target enrollment. Any subsequent open enrollment 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.(5) Initial application period for Category 1 (as announced by the Bureau of TennCare). The State will establish an initial target enrollment figure based on the State's 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:
(a) Callers to the Call-in Line will be asked for basic demographic information and will be assigned a unique identifier.(b) After conducting a match to verify that callers are not already enrolled in TennCare Medicaid and if they are not Medicaid-eligible, the State will send each non-enrolled caller 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. (Those callers who are already enrolled in TennCare Medicaid will be sent letters advising them that they currently have benefits and need not apply.)(c) Completed signed applications received by the State by the 30-day deadline established by the State will be evaluated for Medicaid eligibility and SSD eligibility. Applications received after the deadline will not be reviewed for SSD eligibility but will still 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 or her that since no application was received, the State will not make an eligibility determination for him or her, but the individual is free to apply for SSD during any open enrollment 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 or she did submit a signed, written application within the deadline.(d) Since all SSD applications received during an open enrollment 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 enrollment period will be carried forward to future open enrollment periods. The State will determine SSD eligibility within the timeframes specified by Federal regulations at 42 C.F.R. 435.911; such timeframes will begin on the date a signed written application is received by the State.(6) Effective date of eligibility. The effective date provisions outlined below only apply to SSD eligibility and do not apply to other categories of TennCare eligibility. (a) The effective date of SSD eligibility for individuals whose enrollment is originally initiated through the Call-in Line and who submit a timely signed application will be the later of: 1. The date that their call was received by the Call-in Line; or2. The date spenddown is met (which must be no later than the end of the one month budget period - in this case, the end of the month of the original call to the Call-in Line).(b) The effective date of eligibility for the Transition Group is the later of: 1. The date of the application; or2. The date that spenddown is met - in this case, the end of the month that the application is received by the Department of Human Services.(c) The effective date of eligibility for Medically Needy pregnant women and children under age twenty-one (21) is the later of: 1. The date of application; or2. The date that spenddown is met - in this case, the end of the month that the application is received by the Department of Human Services.(7) Period of eligibility. All enrollees in the SSD demonstration category will have an eligibility period of twelve (12) months from the effective date of the eligibility. At the end of the 12-month period the enrollee will need to 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.Tenn. Comp. R. & Regs. 1240-03-02-.04
Original rule filed June 17, 1976; effective July 14, 1976. Amendment filed June 9, 1981; effective October 5, 1981. Amendment filed November 30, 1981; effective January 14, 1982. Repeal filed August 17, 1982; effective September 16, 1982. New rule filed April 22, 2008; effective July 6, 2008.Authority: T.C.A. §§ 4-5-201 et seq., 4-5-202, 71-1-105(12), 71-5-102 and 71-5-109; 42 U.S.C. §§ 1396 et seq., 42 U.S.C. § 1396a(a)(10)(A)(ii), 42 U.S.C. § 1396a(e)(4) and 42 U.S.C. § 1315; and TennCare II Medicaid Section 1115 Demonstration Waiver.