Section 1200-13-20-.03 - DELINEATION OF ROLES AND RESPONSIBILITIES(1) Agencies' Roles and Responsibilities.(a) TennCare is responsible for determining eligibility for TennCare Medical Assistance and for conducting appeals of eligibility-related decisions, unless otherwise agreed to by the Single State Agency and CMS. TennCare is also responsible for coordinating the eligibility process for Medicaid and CHIP with the eligibility process for APTC/CSR in the FFM, in compliance with 42 C.F.R. §§ 435.1200 and 1205, unless otherwise agreed to by the Single State Agency and CMS.(b) With respect to the eligibility of children applying for TennCare as medically eligible individuals, TennCare is responsible for determining the presence of a qualifying medical condition under TennCare Standard.(c) The Tennessee Department of Children's Services (DCS) is responsible for determining eligibility for Medicaid foster care and adoption assistance categories.(d) The Tennessee Department of Health (DOH) is responsible for conducting presumptive eligibility determinations for pregnant women and individuals in the BCC category.(e) Approved Qualified Hospital Presumptive Eligibility (HPE) Entities are responsible for conducting presumptive eligibility determinations for Former Foster Care, Child MAGI, Caretaker Relative MAGI and Pregnancy MAGI categories.(f) Approved Qualified Entities who are cancer detection and treatment providers are responsible for conducting presumptive eligibility determinations for individuals in the BCC category.(g) The SSA is responsible for determining eligibility for receipt of benefits from the SSI program and for determining TennCare Medicaid eligibility for individuals who are eligible for SSI benefits. 42 U.S.C. § 1383c(a). Individuals determined eligible for SSI benefits and TennCare Medicaid by SSA are automatically enrolled in TennCare Medicaid.(h) The FFM is responsible for making TennCare Medicaid and CoverKids eligibility assessments for categories using MAGI income methodologies, based on an agreement between the State and the FFM. The FFM is also responsible for assessing applicants who may be eligible for other Medicaid eligibility categories and transmitting those applications to the State for full review.(i) TennCare is responsible for notifying applicants of recovery for LTSS expenditures. Section 1917 of the Social Security Act ( 42 U.S.C. § 1396p) , 42 C.F.R. §§ 433.36 and 435.700, et seq., and T.C.A. § 71-5-116.(2) Enrollee Roles and Responsibilities.(a) Each enrollee is responsible for reporting to TennCare any material change in the information affecting eligibility. This information includes, but is not limited to, changes in address, income, household size, employment, or access to insurance. The applicant/enrollee may submit those changes and any required documentation of changes to TennCare via phone, mail, fax, in person, or electronically through TennCare's online portal. Changes must be reported within ten (10) days of the occurrence.(b) All verifications must be furnished within twenty (20) days of the notice requesting additional information unless otherwise specified by federal law.(c) Each TennCare enrollee is responsible for reporting to his provider that he is a TennCare enrollee.(d) By accepting medical assistance through the TennCare program, every enrollee is deemed to assign to the State of Tennessee all third party insurance benefits or other third party sources of medical support or benefits. Individuals applying as Caretaker Relatives under Medicaid (see Rule .07) must cooperate in establishing the paternity of dependent children and obtaining medical support. Failure to cooperate in securing or collecting third party medical insurance, benefits or support is grounds for denying or terminating TennCare eligibility.(e) Upon receipt of a notification of the beginning date of eligibility, each enrollee is responsible for complying with the instructions contained in the notice for submitting requests for reimbursement of costs of covered services incurred during the period of eligibility within sixty (60) days of the date of the notification.Tenn. Comp. R. & Regs. 1200-13-20-.03
Emergency rule filed June 16, 2016; effective through December 13, 2016. New rules filed September 14, 2016; effective December 13, 2016. Amendments filed May 24, 2019; effective 8/22/2019.Authority: T.C.A. §§ 4-5-202, 4-5-208, 71-5-105, 71-5-106, 71-5-110, 71-5-111, and 71-5-117.