Tenn. Comp. R. & Regs. 1240-03-03-.02

Current through October 22, 2024

Section 1240-03-03-.02 - TECHNICAL ELIGIBILITY FACTORS

To be eligible for Medicaid, families or individuals, whether classified as Categorically Needy or Medically Needy, must meet the following requirements, where applicable:

(1) Children otherwise covered under 1240-03-02-.02(3) or adults must not be inmates of a public institution, as that term is defined by Federal regulations and policy.

(2) An aged individual must be at least 65 years of age.

(3) A blind individual must meet the definition of blindness as contained in Title II and XVI of the Social Security Act relating to OASDI and SSI, 42 C.F.R. §435.530.

(4) A disabled individual must meet the definition of permanent and total disability as contained in Titles II and XVI of the Social Security Act relating to OASDI and SSI. Eligibility based on disability is determined in accordance with requirements set out by Titles XVI and XIX of the Social Security Act , 42 C.F.R. §§435.540, 435.541, and 435.911. As Tennessee is a 1634 State, the disability decision made by the Social Security Administration (SSA) for Supplemental Security Income (SSI) applicants is binding on the State Agency's decision for Medicaid only based on disability except when the individual applies for:

(a) Medicaid only and has not applied for SSI or has applied for SSI but was ineligible for a reason other than disability; or

(b) SSI at the Social Security Administration and applies to the State Agency for Medicaid only and the Social Security Administration does not make a disability determination within 90 days from the date of application for Medicaid only; or

(c) Medicaid only and alleges that a different or additional disabling condition exists and was not considered by the Social Security Administration; or

(d) Medicaid only more than 12 months after SSI disability denial and alleges that the disabling condition has changed or deteriorated or applies in less than 12 months of the Social Security Administration's determination alleging his/her condition has changed/deteriorated but the Social Security Administration refused to consider these new allegations and/or he/she is no longer financially or technically (other than disability) eligible for SSI.

(5) An individual must be a citizen of the United States, a naturalized citizen, certain American Indians born outside of the United States, or a qualified alien, unless applying for emergency medical services assistance as an illegal or undocumented alien or one lawfully admitted for residence who is not aged, blind, disabled, or under age eighteen (18). Aliens who entered the United States on or after August 22, 1996 have a five (5) year bar before potential eligibility for TennCare Medicaid unless they meet the exceptions to the five (5) year bar as outlined in the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA).

(a) Each applicant/recipient is required to provide documentary evidence of citizenship and identity when applying for medical assistance. This requirement shall not apply to an individual declaring to be a citizen or national of the United States if they are:

1. A recipient of Medicare; or

2. A recipient of Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI); or

3. A child who is a recipient of foster care or adoption assistance under Title IV-B of the Social Security Act; or

4. A child who is a recipient of foster care or adoption assistance under Title IV-E of the Social Security Act.

(b) All documents must be originals or certified by the issuing agency.

(6) A child up to age twenty-one (21) or a pregnant woman.

(7) An individual must be a resident of the State of Tennessee, as defined by federal regulations at 42 C.F.R. § 435.403, Tennessee Code Annotated § 71-5-120, and as further defined by the Bureau of TennCare.

(8) By accepting medical assistance through the Medicaid program, every recipient is deemed to assign to the State of Tennessee all third party insurance benefits or other third party sources of medical support or benefits. Failure to cooperate in establishing the paternity of dependent children, or in securing or collecting third party medical insurance, benefits or support is grounds for denying or terminating medical eligibility.

(9) Asset Disregards for Qualifying Long Term Care Insurance Policies

(a) Individuals who purchase a qualified long term care insurance policy may have certain assets disregarded in the determination of eligibility for TennCare. The Department of Human Services (DHS) shall disregard an individual's assets up to the amount of payments made by the individual's qualifying long-term care insurance policy for services covered under the policy at the time of TennCare application.

(b) The amount of the individual's assets properly disregarded under these provisions shall continue to be disregarded through the lifetime of the individual.

(c) Assets which were disregarded for purposes of Medicaid eligibility determination during the person's lifetime are also protected from estate recovery. When the amount of assets disregarded during the person's lifetime was less than total benefits paid by the qualified long term care insurance policy, additional assets may be protected in the estate recovery process up to the amount of payments made by the individual's qualifying long term care policy for services covered under the policy. If no assets were disregarded during the person's lifetime, the personal representative may designate assets to protect from estate recovery up to the lesser of the two options specified above, even if a qualified long term care policy's benefits were not completely exhausted.

(10) Institutionalized individuals in a medical institution (i.e., one organized to provide medical care, including nursing and convalescent care) must be likely to be continuously confined for at least thirty (30) consecutive days going forward, as evidenced by an approved NF Preadmission Evaluation eligibility segment which, when combined with the days already confined, total at least 30 days, prior to attaining Medicaid eligibility based on institutionalization. Medicaid eligibility in a NF is retroactive to the later of:

a) the date of admission; or

b) the date of application when thirty (30) consecutive days of institutionalization is met. Coverage of Home and Community Based Services (HCBS) offered either through CHOICES Program or through a Section 1915(c) of the Social Security Act HCBS waiver program requires a determination that the individual needs, and is likely to receive, HCBS services for thirty (30) consecutive days going forward. The effective date of eligibility in the CHOICES 217-Like Group shall be the date the application is approved by DHS, unless TennCare has granted Immediate Eligibility pursuant to Rule 1200-13-01-.05(3)(f), in which case, the effective date of eligibility in the CHOICES 217-Like HCBS Group shall be the effective date of Immediate Eligibility granted by TennCare. In no instance shall the effective date of eligibility precede the date the application was filed with DHS.

(11) As a condition of receiving medical assistance through the Medicaid program, each applicant or recipient must furnish his or her Social Security Number (or numbers, if he/she has more than one) during the application process. If the applicant/recipient has not been issued a number, he/she must assist the eligibility worker in making application for a number or provide verification that he/she has applied for a number and is awaiting its issuance.

Tenn. Comp. R. & Regs. 1240-03-03-.02

Repeal and new rule filed June 14, 1976; effective July 14, 1976. Amendment filed September 15, 1977; effective October 14, 1977. Amendment filed June 9, 1981; effective October 5, 1981. Amendment filed August 28, 1981; effective November 30, 1981. Amendment filed November 30, 1981; effective January 14, 1982. Repeal and new rule filed August 17, 1982; effective September 16, 1982. Amendment filed September 4, 1984; effective October 4, 1984. Amendment filed September 19, 1985; effective October 19, 1985. Amendment filed May 23, 1986; effective August 12, 1986. Amendment filed July 31, 1987; effective September 13, 1987. Amendment filed August 9, 1989; effective September 23, 1989. Amendment filed August 17, 1992; effective October 8, 1992. Amendment filed December 30, 1993; effective March 15, 1994. Amendment filed June 5, 1995; effective August 18, 1995. Amendment filed May 1, 2003; effective July 15, 2003. Public Necessity Rule filed June 1, 2007; expired November 13, 2007. Public necessity rule filed July 2, 2007; effective through December 14, 2007. Amendment filed August 30, 2007; effective November 13, 2007. Amendment filed December 11, 2007; effective February 24, 2008. Amendments filed April 22, 2008; effective July 6, 2008. Amendment filed February 24, 2009; effective May 10, 2009. Emergency rule filed March 1, 2010; effective through August 28, 2010. Amendments filed May 25, 2010; effective August 23, 2010.

Authority: T.C.A. §§ 4-5-201 et seq., 4-5-202, 71-1-105(12), 71-5-101, 71-5-102, 71-5-103, 71-5-106, 71-5-107, 71-5-109, 71-5-111, 71-5-120, 71-5-141 and 71-5-1401 et seq.; Acts 2008, Chapter 1190; 8 U.S.C. §§ 1611, 1612, 1613, and 1641, 42 U.S.C. § 402, 42 U.S.C. § 423, 42 U.S.C. § 672, 42 U.S.C § 673, 42 U.S.C. § 1315, 42 USC §§ 1382c(a)(3) and (4), 42 U.S.C. §§ 1396 et seq., 42 U.S.C. § 1396a(a)(10)(A)(ii)(I) and (V)(VI); 42 U.S.C. § 1396b(v)(1) and (x)(1), (2) and (3); 42 U.S.C. § 1396d and 42 U.S.C. 1396 n(c); 1396(b)(1)(C)(iii) and (b)(5); 42 C.F.R. §§ 435.210, 435.217, 435.300, 435.301, 435.403, 435.406, 435.407, 435.530, 435.540, 435.622, and 435.914(c); PL 104-193 §§ 401, 402, 403 and 431, PL 109-432, Division B, Title IV § 405, December 20, 2006, and PL 109-171 § 6036, 6021; 71 FR 39214 (July 6, 2006); TennCare Medicaid Section 1115 Demonstration Waiver; and Acts 2008, Chapter 1190.