Section 1200-13-20-.07 - FAMILY AND CHILD ELIGIBILITY GROUPS(1) Caretaker Relatives.(a) Definition: See Rule .02.(b) Technical Requirements: See Rule .04.(c) Special Eligibility Requirements: Individual must be a parent or caretaker relative of a dependent younger than age eighteen (18), or 18 and a full-time student, and must agree to cooperate with Child Support Enforcement to establish paternity and medical support, if applicable. Failure to cooperate or show good cause for not cooperating once eligible shall result in termination.(d) Household size is based upon the MAGI household composition Rule .06.(e) Income Limitation: Household income cannot exceed the monthly income levels as outlined in the State Plan.(f) Resource Limitation: None.(g) Effective Date of Eligibility: Eligibility begins on the Application File Date, according to Rule .05, or the date all eligibility requirements are met, whichever is later. Retroactive Eligibility may be granted to eligible pregnant women.(h) Individuals in this category may also be eligible for Extended Medicaid as described in 42 C.F.R. § 435.115 and Transitional Medicaid as described in 42 C.F.R. § 435.112.(2) TennCare Pregnant Women. (a) Definition: See Rule .02.(b) Technical Requirements: See Rule .04.(c) Special Eligibility Requirements: Individual must be pregnant or in the post- partum period as defined in 42 C.F.R. § 435.4. Self-attestation of pregnancy is accepted unless the State has information that is not reasonably compatible with such attestation.(d) Household size is based upon the MAGI household composition Rule .06.(e) Income Limitation: Household income cannot exceed one hundred ninety-five percent (195%) of the FPL. See Rule .06.(f) Resource Limitation: None.(g) Effective Date of Eligibility: Eligibility begins on the Application File Date, according to Rule .05, or the date all eligibility requirements are met, whichever is later. Retroactive Eligibility may be granted to eligible applicants.(h) Other: 1. Eligibility is continuous through the last day of the month of the twelve (12) month postpartum period (beginning on the day her pregnancy ends) regardless of income changes.2. An individual in this category is eligible for all medically necessary covered services, other than LTSS, because TennCare considers all medically necessary covered services to be pregnancy-related. A pregnant woman could be eligible for LTSS if she is determined to meet the criteria for an Institutional Eligibility or ECF CHOICES category.(3) Presumptive Eligibility for Pregnant Women.(a) Definition: See Rule .02.(b) Technical Requirements: See Rule .04. Self-attestation of citizenship, residency and Social Security Number (SSN) are accepted at application for presumptive eligibility.(c) Special Eligibility Requirements: Individual must be pregnant at the time of application. Self-attestation of pregnancy is accepted unless the State has information that is not reasonably compatible with such attestation. (d) Household size is based upon the MAGI household composition Rule .06.(e) Income Limitation: Household income cannot exceed one hundred ninety-five percent (195%) of the FPL. See Rule .06.(f) Resource Limitation: None.(g) Effective Date of Eligibility: The date of determination by the Tennessee Department of Health or other qualified entity. The presumptive eligibility period ends either the last day of the month following the month a presumptive eligibility determination was made, or if a full Medicaid application is submitted before the end of the month following the presumptive application, eligibility continues until a determination is made on a complete Medicaid application, or as otherwise agreed to by the Single State Agency and CMS. Only one presumptive period of eligibility is allowed for each pregnancy.(4) Infants and Children under Age 19. (a) Definition: See Rule .02.(b) Technical Requirements: See Rule .04.(c) Special Eligibility Requirements: Individual must be younger than nineteen (19) years of age.(d) Household size is based upon the MAGI household composition Rule .06.(e) Income Limitations: 1. Infants younger than age one (1): Household income cannot exceed one hundred ninety-five percent (195%) of the FPL.2. Children from age one (1) to age five (5): Household income cannot exceed one hundred forty-two percent (142%) of the FPL.3. Children from age six (6) to age nineteen (19): Household income cannot exceed one hundred thirty-three percent (133%) of the FPL. See Rule .06.(f) Resource Limitations: None.(g) Effective Date of Eligibility: Eligibility begins on the Application File Date, according to Rule .05, or the date all eligibility requirements are met, whichever is later. Retroactive Eligibility may be granted to eligible applicants.(h) Individuals in this category may also be eligible for Extended Medicaid as described in 42 C.F.R. § 435.115 and Transitional Medicaid as described in 42 C.F.R. § 435.112.(5) Deemed Newborns. (a) Definition: See Rule .02.(b) Technical Requirements: See Rule .04, except Deemed Newborns are not subject to citizenship rules. Newborns without an SSN must be enumerated by age one (1) to remain eligible for another category, or before they can be approved in another category, whichever occurs first.(c) Special Eligibility Requirements: Newborns must be twelve (12) months or younger. A baby born to a mother eligible for and receiving TennCare Medicaid shall be eligible for TennCare Medicaid for one (1) year from the date of birth, as long as the newborn remains a resident of Tennessee during that time.(d) Income Limitations: None.(e) Resource Limitations: None.(f) Effective Date of Eligibility: The child's date of birth, if mother was eligible for and receiving TennCare Medicaid at the time of birth.(6) Former Foster Care Children up to Age 26. (a) Definition: See Rule .02.(b) Technical Requirements: See Rule .04.(c) Special Eligibility Requirements: The individual must be under age twenty-six (26), have been in foster care provided by the State of Tennessee, and must have been receiving Medicaid in the foster care category at the time he aged out of custody in order to qualify for this category.(d) Income Limitations: None.(e) Resource Limitations: None.(f) Effective Date of Eligibility: Eligibility begins on the Application File Date, according to Rule .05, or the date all eligibility requirements are met, whichever is later.(7) Standard Child Uninsured. (a) Definition: See Rule .02.(b) Technical Requirements: See Rule .04.(c) Special Eligibility Requirements: Must be a Medicaid "Rollover" enrollee as defined in Rule .02, or currently enrolled in TennCare Standard, and does not have insurance or access to health insurance.(d) Household size is based upon the MAGI household composition Rule .06.(e) Income Limitations: Household income must be below two hundred eleven percent (211%) of the FPL.(f) Resource Limitations: None.(g) Effective Date of Eligibility: The day following the TennCare Medicaid coverage end date.(h) Other: Includes 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 and eleven percent (211%) of the FPL, and who have not purchased insurance even if they have access to it. This is a "grandfathered" eligibility category. If an individual loses eligibility in this category, he will not be able to re-enroll in it.(8) Standard Child Medically Eligible.(a) Definition: See Rule .02.(b) Technical Requirements: See Rule .04.(c) Special Eligibility Requirements: Must be an uninsured child under age nineteen (19) who is losing eligibility for Medicaid or being renewed as TennCare Standard, who does not have access to health insurance, and who has been determined to have a qualifying medical condition according to these rules.(d) Special Application Procedures: 1. Must be a Medicaid "Rollover" enrollee as defined in Rule .02, or currently enrolled in TennCare Standard.2. Applicants have three (3) options for proving medical eligibility: (i) Option 1: Physician's attestation on the Medically Eligible (ME) Packet of specific qualifying conditions.(ii) Option 2: A completed ME packet and medical records to support a qualifying medical condition with a signed release for medical records in the event additional medical records are needed.(iii) Option 3: An existing Medically Eligible determination in Interchange.3. 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 two hundred eleven percent (211%) of the FPL or higher, he will be sent a ME packet.4. TennCare will send the enrollee a ME packet with an explanation regarding how to apply for TennCare Standard as a medically eligible individual. The enrollee will have sixty (60) days from the date of the notice 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.5. The required ME application information must be returned to the address specified within sixty (60) days from the date of the letter included in the packet. A ME 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.(e) Household size is based upon the MAGI household composition Rule .06.(f) Income Limitations: Household income must be at or above two hundred eleven percent (211%) of the FPL.(g) Resource Limitations: None.(h) Effective Date of Eligibility: The day following the TennCare Medicaid coverage end date.(9) CoverKids CHIP Children under Age 19.(a) Definition: See Rule .02.(b) Technical Requirements: See Rule .04.(c) Special Eligibility Requirements: Includes children under age 19 who do not have Health Insurance, as defined in Rule .02.(d) Household size is based upon the MAGI household composition Rule .06.(e) Income Limitations: Must be over the applicable Medicaid limit and no more than two hundred fifty percent (250%) of the FPL. See Rule .06.(f) Resource Limitations: None.(g) Effective Date of Eligibility: Eligibility begins on the Application File Date, according to Rule .05, or the date all eligibility requirements are met, whichever is later.(10) CoverKids Pregnant Women. (a) Definition: See Rule .02.(b) Technical Requirements: See Rule .04. The pregnant woman's unborn child is presumed to be a U.S. citizen, regardless of the citizenship or immigration status of the mother. The mother is not required to provide proof of citizenship or immigration status.(c) Special Eligibility Requirements: Includes pregnant women who do not have Health Insurance, as defined in Rule .02, or do not have maternity benefits or have exhausted maternity benefits.(d) Household size is based upon the MAGI household composition Rule .06.(e) Income Limitations: Must be ineligible for Medicaid and no more than two hundred fifty percent (250%) of the FPL. See Rule .06.(f) Resource Limitations: None.(g) Effective Date of Eligibility: Eligibility begins on the Application File Date, according to Rule .05, or the date all eligibility requirements are met, whichever is later.(h) Other: Eligibility for the pregnant woman is continuous through the 60 days postpartum period as defined at 42 C.F.R. § 435.4. Eligibility for the newborn child continues twelve (12) months from the mother's effective date of eligibility.(11) IE Foster Care, Foster Care, and Adoption Assistance. (a) Definition: Children in State foster care or in a subsidized adoptive home.(b) Eligibility for these categories is determined by the Tennessee Department of Children's Services.(12) Transitional Medicaid. (a) Definition: See Rule .02.(b) Technical Requirements: See Rule .04.(c) Special Eligibility Requirements for Children: Transitional Medicaid benefits are provided to children who lose Child MAGI eligibility when the following conditions are met: 1. The child's parent or caretaker relative was previously eligible in a MAGI category with income under the Caretaker Relative income standard for three (3) of the previous six (6) months but lost eligibility due to an increase in earnings; and2. The child was eligible and enrolled in a Child MAGI category for three (3) of the six (6) months immediately preceding the month the parent or caretaker relative lost eligibility.(d) Special Eligibility Requirements for Caretaker Relatives: Transitional Medicaid benefits are provided to parents and caretaker relatives who lose Caretaker Relative MAGI eligibility when all of the following conditions are met: 1. The individual was eligible and enrolled in the Caretaker Relative MAGI category for three (3) of the six (6) months immediately preceding the month eligibility was lost;2. Loss of eligibility was due to an increase in earnings; and3. The parent or caretaker relative must continue to have a dependent child in the home in order to receive Transitional Medicaid.(e) Household size is based upon the MAGI household composition Rule .06.(f) Income Limitations: See Rule .06.(13) Extended Medicaid. (a) Definition: See Rule .02.(b) Technical Requirements: See Rule .04.(c) Special Eligibility Requirements: Eligible individuals must have been eligible for and receiving benefits for at least three (3) out of six (6) months immediately preceding the month of ineligibility.(d) Special Eligibility Requirements for Children: Extended Medicaid benefits are provided to children who lose Child MAGI eligibility when the following conditions are met:1. The child's parent or caretaker relative was previously eligible in a MAGI category with income under the Caretaker Relative income standard for three (3) of the previous six (6) months but lost eligibility due to an increase in spousal support; and2. The child was eligible and enrolled in a Child MAGI category for three (3) of the six (6) months immediately preceding the month the parent or caretaker relative lost eligibility.(e) Special Eligibility Requirements for Caretaker Relatives: Extended Medicaid benefits are provided to parents and caretaker relatives who lose Caretaker Relative MAGI eligibility when the following conditions are met:1. The individual was eligible and enrolled in the Caretaker Relative MAGI category for three (3) of the six (6) months immediately preceding the month eligibility was lost;2. Loss of eligibility was due to an increase in spousal support; and3. The parent or caretaker relative must continue to have a dependent child in the home in order to receive Extended Medicaid.(f) Household size is based upon the MAGI household composition Rule .06.(g) Income Limitations: See Rule .06.(14) Hospital Presumptive Eligibility.(a) Definition: See Rule .02.(b) Technical Requirements: See Rule .04. Self-attestation of citizenship, residency and Social Security Number (SSN) are accepted at application for presumptive eligibility.(c) Special Eligibility Requirements: Self-attestation of pregnancy is accepted unless the State has information that is not reasonably compatible with such attestation.(d) Household size is based upon the MAGI household composition Rule .06.(e) Income Limitation: Household income must not exceed the income standard for the TennCare Medicaid category for which the individual's presumptive eligibility is being determined.(f) Resource Limitation: None.(g) Effective Date of Eligibility: The date of determination by the qualified entity. The presumptive eligibility period ends either the last day of the month following the month a presumptive eligibility determination was made, or if a full Medicaid application is submitted before the end of the month following the presumptive application, eligibility continues until a determination is made on a complete Medicaid application, or as otherwise agreed to by the Single State Agency and CMS. Applicants are allowed one period of HPE every two calendar years for non-pregnancy-related categories. For pregnant women, one period of presumptive eligibility is allowed per pregnancy.Tenn. Comp. R. & Regs. 1200-13-20-.07
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 August 22, 2019. Amendments filed May 13, 2022; effective 8/11/2022.Authority: T.C.A. §§ 4-5-202, 4-5-208, 71-5-105, 71-5-106, 71-5-109, 71-5-110, 71-5-111, and 71-5-117.