Section 1200-13-20-.08 - AGED, BLIND OR DISABLED CATEGORIES(1) Supplementary Security Income (SSI) Cash recipient. (a) Aged, blind or disabled individuals who are determined eligible for SSI payments by the SSA are eligible for TennCare Medicaid. Once SSI payments in Tennessee stop, the individual becomes an inactive SSI enrollee who must be reviewed for eligibility in all other categories.(b) Effective date of eligibility: Date of eligibility as determined by the SSA.(2) Disabled Adult Child. (a) Definition: See Rule .02.(b) Technical Requirements: See Rule .04.(c) Special Eligibility Requirements: Disabled adult children who lose SSI eligibility after July 1, 1987 because of the receipt of or increase in DAC payments under Title II of the Social Security Act will remain eligible for Medicaid if the initial entitlement or increase under Title II, whichever caused the ineligibility for SSI, and any subsequent COLA and non-COLA increases, were disregarded. Individuals must have been age 18 or older when SSI terminated.(d) Income Limitations: SSI Federal Benefit Rate.(e) Resource Limitations: $2,000.00 for an individual, $3,000.00 for a couple.(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.(3) Pickle Passalong. (a) Definition: See Rule .02.(b) Technical Requirements: See Rule .04.(c) Special Eligibility Requirements: TennCare Medicaid benefits are available to individuals who would be eligible for SSI payments if increases in their OASDI due to COLAs were disregarded. Individuals who meet all other non-financial and financial eligibility requirements remain eligible for TennCare Medicaid if they: 1. Currently receive OASDI authorized under Title II of the Social Security Act;2. Are not currently receiving SSI;3. Were entitled to both OASDI and SSI benefits in the same month after April 1977; and4. Have countable income equal to or less than the current SSI Federal Benefit Rate after all COLAs received since the last month in which the individual was eligible for both OASDI and SSI have been deducted.(d) Income Limitations: SSI Federal Benefit Rate.(e) Resource Limitations: $2,000.00 for an individual, $3,000.00 for a couple.(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.(4) Widow/Widower. (a) Definition: See Rule .02.(b) Technical Requirements: See Rule .04.(c) Special Eligibility Requirements. A disabled widow/widower is eligible for TennCare Medicaid for any month in which he is entitled to a Social Security Widow/Widower benefit, but is not eligible for SSI, if he:1. Was eligible for SSI based on his own disability;2. Was entitled to the Social Security Widow/Widower benefit any time after the age of fifty (50);3. Lost SSI eligibility in the first month that the Social Security Widow/Widower benefit was paid;4. Would be eligible for SSI if the Widow/Widower entitlement and all subsequent COLAs were disregarded;5. Is not entitled to Medicare Part A; and6. Is at least age fifty (50) and under age sixty-five (65).(d) Income Limitations: SSI Federal Benefit Rate.(e) Resource Limitations: $2,000.00 for an individual, $3,000.00 for a couple.(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.(5) Institutional Eligibility. (a) Definition: See Rule .02.(b) Technical Requirements: See Rule .04.(c) Special Eligibility Requirements. To gain eligibility in this category, applicants must: 1. Be confined in a Medical Institution at least thirty (30) consecutive days and be either Aged, Blind, Disabled, a child under age twenty-one (21), or a pregnant woman2. Meet Nursing Facility Level of Care (NF LOC) according to Chapter 1200-13-01; or3. Receive CHOICES HCBS and meet the medical Level of Care (LOC) eligibility criteria, according to Chapter 1200-13-01, to receive payments for LTSS through CHOICES.4. An individual who receives hospice services in a nursing facility for any length of time or dies in a nursing facility or ICF/IID prior to thirty (30) days of continuous confinement meets the 30-day continuous confinement requirement.(d) Household size is based upon the ABD household composition Rule .06.(e) Income Limitations: Income shall not exceed three hundred percent (300%) of the SSI Federal Benefit Rate for an individual.(f) Resource Limitations: Resources shall not exceed $2,000.00 for an individual.(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) Special Asset Rules: 1. Asset Disregards for Qualified Long-Term Care Insurance Policies.(i) Individuals who purchase a qualified long term care insurance policy may have assets disregarded in the determination of eligibility for TennCare. TennCare 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.(ii) The amount of the individual's assets properly disregarded under these provisions shall continue to be disregarded through the lifetime of the individual.(iii) Assets disregarded during the TennCare Medicaid eligibility determination process because the enrollee purchased an LTCP policy are protected from estate recovery. When the amount of assets disregarded during the TennCare Medicaid eligibility determination process are less than the total benefits paid by the LTCP policy, additional assets up to the total amount of payments made by the LTCP policy may be protected during the estate recovery process.2. Entrance Fees: Any contractual provision requiring the resident to deposit entrance fees must take into account the required allocation of resources or income to the community spouse before determining the resident's cost of care. In addition, the entrance fee paid to the Continuing Care Retirement Community (CCRC) or life care community is treated as a resource to an individual for purposes of determining Medicaid eligibility. The following three (3) conditions must be met in order for the entrance fee to be considered an available resource: (i) Any portion of the entrance fee is refunded or used to pay for care under the terms of the entrance contract should other resources of the individual be insufficient;(ii) The entrance fee, or any portion thereof, is refundable under the terms of the contract when the individual dies or terminates the contract and leaves the CCRC or life care community, whether or not any amount is actually refunded; and(iii) The entrance fee does not confer an ownership interest in the community.3. Funds used to purchase a loan, mortgage or promissory note after February 8, 2006 must be treated as a transfer of assets unless it has a repayment term that is actuarially sound, provides for payments to be made in equal amounts during the term of the loan with no deferral or balloon payment, and prohibits cancellation of the balance upon the death of the lender. If a nursing home applicant uses his funds to purchase a loan, mortgage or promissory note and the purchase agreement does not meet the criteria of this part, the amount of the asset transfer will be the outstanding balance due on the loan, mortgage or promissory note as of the date of the application for Medicaid.4. A life estate interest purchased by a nursing home applicant in another individual's home shall be treated as a transfer of assets unless the nursing home applicant resides in the home for a period of at least one (1) year after the date of the purchase.(i) Transfer of Assets. A transfer of assets is transferring ownership of a resource for less than fair market value (FMV). An applicant requesting payment for LTSS shall not transfer assets for less than FMV on or after the look-back date. The look-back date is sixty (60) months prior to the first date an individual has both applied for Medicaid and is institutionalized or is determined to have met the requirements for HCBS. If an individual is found to have transferred an asset for less than FMV, he will be ineligible for payments for LTSS. 1. An individual shall not receive a period of ineligibility to the extent that the transfer meets the requirements of 42 U.S.C. § 1396p(c)(2).2. An individual shall not receive a period of ineligibility to the extent that the assets: (i) Were transferred to a trust established solely for an individual under age 65 and that meets the requirements of 42 U.S.C. § 1396p(d)(4)(A);(ii) Were transferred to a trust that meets the requirements of 42 U.S.C. § 1396p(d)(4)(B); or(iii) Were transferred to a trust established solely for the benefit of an individual under the age of 65 who is disabled according to the Social Security Administration and that meets the requirements of 42 U.S.C. § 1396p(d)(4)(C). Trusts created pursuant to this section shall not include language disallowing repayment to the state in the event the claim exceeds the amount remaining in the trust.(iv) All trusts may be subject to review annually or upon request for a full accounting by TennCare. Failure to respond to such requests or provide this information may result in the ineligibility of an individual.3. The transfers indicated below, if occurring on or after February 8, 2006, may be considered a transfer of assets for less than FMV with respect to an individual applying for Medicaid based on institutionalization: (i) If the transfer of assets occurs on or after the look-back date.(ii) If the institutionalized individual, his spouse, or any person, court or administrative body with authority to act on behalf of, or at the direction or request of, the individual or his spouse, establishes a trust or similar device, which includes the individual's assets and cannot be used by or for the individual's benefit, if it occurred on or after the look-back date.(iii) If an asset is held jointly by the institutionalized individual with another person and the individual or other owner reduces or eliminates the institutionalized individual's ownership or control of the asset, if it occurred on or after the look-back date.(j) Penalty for transfer of assets. 1. The institutionalized individual may be subject to penalty if the transfer was completed by the individual; the individual's spouse; a person (including a court) or administrative body with legal authority to act in place of, or on behalf of, or at the direction or request of the institutionalized individual or his spouse.2. Assets include all income and resources, including the home, unless transferred as indicated in subparagraph (i) above, of the institutionalized individual and his spouse, (including income and/or resources the individual is entitled to, but does not receive because of any action by the individual or his spouse or a person (including a court) or administrative body with legal authority to represent the individual, his spouse, or who acts at the direction or request of the individual and his spouse).3. Penalty period: The period of ineligibility for payments for long-term services and supports in the CHOICES Program imposed for transfers of assets within sixty (60) months prior to application for long term care nursing services. (i) The penalty period is determined by dividing the uncompensated value of the transferred asset by the average daily nursing home private pay rate. In determining the penalty for a transfer a State may not round down or disregard any fractional period of ineligibility. There is no limit on the maximum months of ineligibility. The penalty continues until expired unless hardship is considered to exist.(ii) The penalty period for individuals receiving nursing home care begins the date the individual is eligible for Medicaid and would otherwise be receiving LTSS through the CHOICES program but for a penalty or the first day of the month of the transfer, whichever is later. The penalty period for HCBS begins the date the individual meets all eligibility requirements and would otherwise be receiving LTSS through the CHOICES program but for a penalty or the first day of the month of the transfer, whichever is later. The penalty period runs consecutively even if the individual leaves the nursing home for a period of time and later returns. If a penalty period is imposed for new applicants, Medicaid requires a notice of penalty. If a penalty period is imposed on an individual who is already receiving Medicaid, a ten (10) day adverse action notice is required.(iii) Applicants for, or enrollees in, nursing home coverage can still remain eligible in an Institutional Eligibility category while payments for LTSS are withheld. Applicants for, or enrollees in, HCBS cannot be eligible for an Institutional Eligibility category while subject to the period of ineligibility.(iv) Penalty periods for more than one transferred asset will run consecutively, not concurrently. Any uncompensated value from multiple transfers is added to the initial uncompensated value if penalty periods overlap to determine the consecutive penalty period.(k) Undue hardship. 1. Undue Hardship shall exist only when: (i) The individual has been denied LTSS payments due to one of the following reasons. (I) The value of the homestead property exceeds the home equity limit;(II) An Estranged Spouse's failure to cooperate with the resource assessment process;(III) A penalty period is applied due to the transfer of asset provision; or(IV) The applicant is resource ineligible due to the provisions of a trust, and the applicant is otherwise resource eligible.(ii) The ineligibility for LTSS payments would deprive the individual of medical care, such that the individual's health or life would be endangered, or of food, clothing, shelter, or other necessities of life;(iii) The institutionalized individual has no available resources (other than the uncompensated value) in excess of the resource limitations, and(iv) The necessary care is not available from any other source.2. The individual, the individual's responsible party, or the facility in which an institutionalized individual resides may file an Undue Hardship claim on behalf of the applicant/recipient.3. An Undue Hardship claim must be filed within ninety (90) days of the Application File Date, or no later than forty (40) days after the date of the denial or termination notice. However, an undue hardship claim can also be filed if an individual experiences a change in circumstances while in a penalty period.4. TennCare will determine whether Undue Hardship exists and notify the Applicant within thirty (30) days of filing.5. If Undue Hardship is determined not to exist, the denial of Undue Hardship may be appealed within forty (40) days.(l) Patient Liability. Individuals determined eligible for institutional services are required to contribute to the cost of their care as a resident in a nursing facility or as a Home and Community Based Services (HCBS) recipient. Patient liability is calculated based on total income remaining after deductions in accordance with 42 C.F.R. § 435.725, 42 C.F.R. § 435.726, and the State Plan. Total income includes all amounts of income available to an individual from all sources, which are considered to be income for eligibility purposes, unless specifically excluded from post-eligibility under the State Plan or based on other Federal laws.1. Post-Eligibility Treatment of Certain Payments from the Department of Veterans Affairs. VA improved pensions limited to $90 per month are not considered in the post-eligibility process. If an unmarried, childless veteran or the surviving, childless spouse of a veteran is in a state veterans home and receives a VA pension that exceeds $90 per month, the VA pension, including any payment made for aid and attendance or for unreimbursed medical expenses, is counted in total income and applied to the state veterans home's cost of providing nursing home care to the veteran or surviving spouse.2. Patient liability is determined by allowing the following deductions from an individual's total income: (i) A Personal Needs Allowance (PNA) for clothing and other personal needs while receiving Institutional Eligibility. Apply the appropriate PNA based on the type of long term services and supports the individual receives, as follows:(I) Nursing Facility. $50.00 PNA from the gross income of an individual in a nursing facility or ICF/IID. For an individual with greater need who participates in a sheltered workshop, subtract up to $100 of earnings plus $50 for the PNA.(II) HCBS, PACE, ECF and Self-Determination ID Waivers. PNA is three hundred percent (300%) of the SSI FBR.(III) Statewide ID and Comprehensive Aggregate Cap ID Waivers. PNA is two hundred percent (200%) of the SSI FBR.(ii) An allowance equivalent to the monthly fee for maintenance of a QIT, if applicable.(iii) A CSIMA for institutionalized individuals with a spouse residing in the community.(iv) A DIMA for institutionalized individuals with a dependent residing in the community.(v) Health insurance premiums, coinsurance and deductibles.(vi) Expenses for medical services as defined at 42 C.F.R. §§ 435.725(c) (4) and 726(c)(4).3. Community Spouse Income Maintenance Allowance (CSIMA). When determining an institutionalized individual's patient liability, an allowance is deducted from his income for the needs of the community spouse. The CSIMA is allowed unless specifically refused by the institutionalized spouse. Funds must actually be transferred to the community spouse in order to be deducted. (i) CSIMA is allowed under the following conditions:(I) CSIMA is not allowed if both spouses are receiving Institutional Eligibility, unless one spouse is receiving HCBS.(II) If the community spouse applies for TennCare Medicaid, the CSIMA will be counted as unearned income at the time of application.(III) A community spouse receiving need-based assistance does not have to accept the total or any of the income allocation if it will result in the termination or decrease of those benefits.(IV) If a couple is married but living separately, and considers themselves to be separated, the CSIMA may be allowed if both individuals agree to the allocation and the community spouse is not institutionalized.(V) If the community spouse lives out of State, the CSIMA is allowed if the community spouse can be located and the couple is still married.(ii) CSIMA Terms and Standards: (I) Standard Maintenance Amount (SMA): The poverty level standard used to determine the community spouse's monthly maintenance needs. The SMA is 150% of the FPL for a household of 2. This is subject to annual change by CMS and released with SSI and Spousal Impoverishment Standards.(II) Maintenance Needs Standard: The minimum amount of monthly income necessary to meet the community spouse's maintenance needs and prevent impoverishment. The Maintenance Needs Standard is determined by adding the SMA and the Excess Shelter Allowance (ESA). This is subject to annual change by CMS and released with SSI and Spousal Impoverishment Standards.(III) Standard Utility Amount (SUA): The SUA is used when the community spouse is responsible for heating and/or cooling costs. If the SUA is used, then it is considered to cover all utilities, including garbage, water, lighting, etc. The SUA is subject to annual change by the Tennessee Department of Human Services.(IV) Standard Housing Allowance (SHA): The SHA is used to determine whether the community spouse requires an Excess Shelter Allowance. This is subject to annual change by CMS and released with SSI and Spousal Impoverishment Standards.(iii) CSIMA Calculation: The CSIMA is calculated using three steps:(I) Determine Excess Shelter Allowance (ESA).I. An ESA is allowed when the total shelter costs for rent, mortgage, taxes and insurance, maintenance charges and utility costs exceed the SHA. The SHA is thirty percent (30%) of the Standard Maintenance Amount.II. The SUA is used when the community spouse is responsible for heating or cooling costs. If the SUA is used then it is considered to cover all utilities (no additional allowance for garbage, telephone, etc.). When there is no or reduced cost to the community spouse because the cost of a particular utility is paid by a third party (in cash or in-kind), reduce the amount of the SUA by the third party payment.III. To determine the ESA, add rent, mortgages, taxes, insurance, etc., to the SUA, then subtract the SHA. (II) Determine Community Spouse Net Income. Defined as income over which the Community Spouse has control and which is actually available to him. Child support payments and other types of court-ordered payments made by the Community Spouse are not considered income available to the Community Spouse.(III) Calculate CSIMA: The CSIMA is calculated by adding the SMA and the ESA, and then subtracting the Community Spouse's net income.4. Dependent Income Maintenance Allowance (DIMA): When determining patient liability, an allowance is deducted from the individual's income for the needs of his dependents living at home. (i) Dependent relatives include the individual's or the spouse's adult dependent children, parents, siblings, and minor children who are living at home.(ii) A DIMA is not allowed for any dependent receiving HCBS or who is institutionalized.(iii) Pursuant to the Medicare Catastrophic Coverage Act, a dependent does not have the option of declining all or a portion of the income allocation for any reason, even if needs-based benefits may be decreased or lost because of the allocation.(iv) The DIMA for each additional dependent family member living with the community spouse is equal to one-third of the difference between the SMA and the dependent's gross income.(v) DIMA Calculation: The dependent allocation(s) equals the SMA for the community spouse minus the dependent's own gross countable income divided by 3.(vi) The DIMA for dependent relatives living in the home without a community spouse is determined based on the MNIS.(vii) DIMA Calculation: The dependent allocation is the MNIS for the household size if the total net countable income of the dependent(s) is less than the MNIS. No dependent allocation is given if the total net countable income of the dependent(s) is more than the MNIS for the household size.5. Incurred Medical Expenses: Expenses for medical or remedial care not subject to third party payment as defined at 42 C.F.R. §§ 435.725(c)(4), 435.726(c)(4) and 435.832, and outlined in the State Plan are allowable deductions. Criteria for Deduction of an Incurred Medical Expense:(i) The expense must not be subject to payment by a third party not expecting reimbursement, e.g., medical or health insurance, the individual's spouse or family or medical trust fund, Medicare, etc.(ii) The expense may be unpaid or paid by the individual during the month(s) of eligibility determination or paid by a member of the individual's family and reimbursement is expected by the family member.(iii) The expense must not have been allowed previously as an allowed necessary item.(iv) If payment for the item is outstanding, it must be considered collectible by the party who provided the medical service and one for which the individual is legally liable.(v) Medical expenses incurred during a period of ineligibility and up to three months prior to the month of application may be allowable medical expenses.(vi) Deductions will be allowed in compliance with 42 C.F.R. §§ 435.725(c)(4), 435.726(c)(4), and 435.832, and the State Plan.(m) Resource Assessment and CSRMA. 1. Resource Assessment: When determining eligibility for a married, institutionalized Applicant a calculated amount of the couple's assets is allocated to the Community Spouse to be used for her own needs. The resource assessment is a snapshot of all countable assets owned by the couple at the time of the first period of continuous confinement but conducted upon application or when an assessment is requested prior to application. For applicants in a Medical Institution, it is a snapshot of the couple's assets on the date of admission to a Medical Institution. For HCBS applicants, it is a snapshot on the effective date of the approved Pre-Admission Evaluation (PAE). If an application for HCBS is filed before a PAE has been approved, and the PAE is approved within 90 days of application, the snapshot date for the resource assessment is the Application File Date. All of the countable resources owned individually or jointly by both spouses are counted; resources excluded under the ABD resource rules are not counted in the resource assessment.(i) Only one resource assessment will be completed for a married couple.(ii) Under no circumstances can a resource assessment be completed prior to the first continuous period of institutionalization.(iii) For residents in a Medical Institution, an assessment remains in effect until a TennCare application is filed, regardless of any interruptions in confinement. For HCBS, the effective date of the earliest approved PAE should be used to conduct the resource assessment, as long as the individual continues to meet the medical level of care at the time an application for HCBS is filed. If a resource assessment is completed and the individual applies for TennCare Medicaid, but is found ineligible, the original resource assessment is still valid if the individual applies again in the future.2. Community Spouse Resource Maintenance Allowance: The CSRMA is based on the spouses' combined countable resources documented in the Resource Assessment. The amount of the CSRMA is the greater of:(i) One-half (1/2) of the total countable resources, but not less than the Minimum Resource Standard or greater than the Maximum Resource Standard (released in the SSI and Spousal Impoverishment Standards and subject to change annually);(ii) The court-ordered amount; or(iii) The amount determined by an Administrative Judge due to a hardship situation (extreme financial duress).3. When an application is filed by or on behalf of the spouse seeking LTSS, the CSRMA amount determined in the resource assessment is the amount allocated to the community spouse. This amount is deducted from the combined resources of both spouses as of the first day of the first month for which assistance is requested. None of the community spouse's share of the resources is considered available to the individual seeking eligibility when determining her TennCare Medicaid eligibility.4. Refusal of CSRMA. A community spouse who receives needs-based assistance may accept or decline all, some or none of the CSRMA if the allocation would cause the loss of or decrease in those program benefits. If the community spouse accepts only a portion of the CSRMA, the unclaimed portion of the CSRMA is counted as part of the institutionalized spouse's resources.5. Resource Transfer as a Result of Assessment.(i) CSRMA "Grace Period." Following a resource assessment and initial approval of eligibility, resources must be transferred within twelve (12) months of the approval. Both spouses must agree to the transfer in order to use the institutionalized spouse's share in determining his eligibility. The transfer may require conveyance of resources from the institutionalized individual to the community spouse, or vice versa.(ii) Transfer Refusal. When the community spouse refuses to transfer resources to the institutionalized individual, the institutionalized spouse may still be eligible if on appeal the State finds that undue hardship circumstances exist. (I) If the community spouse has available assets over the CSRMA she is legally obligated to provide support.(II) Hardship cannot be determined to exist unless assets have been reallocated as the result of an appeal decision or a court order.(iii) CSRMA Appeals.(I) When the Individual and/or Spouse Has Appeal Rights. Appeal rights are considered only after a TennCare application has been filed and either spouse alleges that the assessment or eligibility determination decision is not correct. An assessment completed exclusive of a filed application cannot be appealed, 42 U.S.C. § 1396r-5(e)(2)(A). Revisions to the spousal allowance of resources can be made by an Administrative Judge or by court order.(II) CSRMA Revisions. The amount of the CSRMA may only be revised by an Administrative Judge or by court order, and only if additional verification/documentation is provided. The CSRMA may only be revised when:I. The initial assessment was alleged to be incorrect and the Administrative Judge confirms the allegations;II. An Administrative Judge determines a larger CSRMA is necessary to raise the community spouse's available income to the Maintenance Needs Standard or to an amount by which exceptional maintenance needs, established at a fair hearing, exceed the community spouse's income; orIII. A court order is received against an institutionalized spouse for the support of the community spouse and resources are transferred pursuant to the court order.(III) Allocation of Additional Resources to the Community Spouse. I. When Additional Resources May be Allocated to Community Spouse: In the event that the institutionalized spouse does not have enough income to provide the community spouse with sufficient income to meet the Maintenance Needs Standard and the CSRMA is not enough to offset the income shortfall, additional resources may be allocated to the community spouse by an Administrative Judge if the couple has additional resources above the community spouse's protected amount (CSRMA).II. The Deficit Reduction Act (DRA) of 2005 requires all States to allocate the maximum amount of available income of the institutionalized spouse to the community spouse before granting an increase in the CSRMA. This is referred to as the "income-first" method.III. TennCare uses the Single Fixed Annuity model to address appeals when there is insufficient income to provide the community spouse with the Maintenance Needs Standard and the couple has additional resources. A single fixed annuity can turn a portion of an individual's savings into income payments made for the rest of the individual's life. The procedure for establishing a Single Fixed Annuity is listed below. A. Additional resources may be allocated to the community spouse through the TennCare eligibility appeals process to make up any shortfall between the amount of income allocated from the institutional spouse to the community spouse and the Maintenance Needs Standard, if determined appropriate.B. The amount of additional resources that are necessary to cover the income shortfall shall be determined in reference to the purchase of a Single Premium Annuity as follows:(A) By calculating the shortfall between the amount of income allocated and the Maintenance Needs Standard, and then determining the amount of additional resources that must be invested in a single premium annuity in order to generate the income necessary to cover the shortfall.(B) The amount of resources needed to cover the shortfall shall be determined in reference to an annuity calculator as adopted by TennCare.(C) Additional Resources may be allocated to the community spouse if the amount of resources needed to cover the shortfall is greater than the CSRMA.C. The additional resource allocation to the community spouse does not require the actual purchase of a Single Premium Annuity that is used for purposes of calculating the amount of the additional resource allocation.D. If a single premium annuity is actually purchased pursuant to these rules, the annuity must comply with all other relevant requirements of state and federal law.E. The amount of additional resources that are necessary to cover the shortfall shall not be determined in reference to any investment which contemplates the return of the entire principal at maturity.(iv) Transfer of Assets for Less than Fair Market Value.(I) A transfer of assets for less than FMV is not considered to have occurred when resources are transferred from the institutionalized individual to the community spouse or vice versa according to a completed resource assessment.(II) Should the spouse who received the allocation according to the resource assessment then transfer the resource to someone else for less than FMV, the transfer will not be treated as a transfer of assets since the resources of a couple are treated separately after the establishment of Institutional Medicaid eligibility.(III) Transfer of assets for less than FMV is considered part of the application process whether or not a resource assessment has been requested previously or is requested at application. Transfer of assets is not considered if a resource assessment only (no TennCare Medicaid application filed concurrently) is requested.(6) ECF CHOICES Demonstration Groups.(a) ECF CHOICES 217-Like Group.1. Definition: See Rule .02.2. Technical Eligibility Requirements: See Rule .04.3. Special Eligibility Requirements: To gain eligibility in this category, applicants must: (i) Have an Intellectual Disability manifested before eighteen (18) years of age or a Developmental Disability manifested before twenty-two (22) years of age, as specified in T.C.A. § 33-1-101.(ii) Be in one of the defined target populations specified in Chapter 1200-1301-.31.(iii) Meet Nursing Facility Level of Care (NF LOC), as defined in Chapter 1 20013-01-.02.(iv) Qualify for an available slot in an ECF CHOICES Group defined at 1 20013-01-.02(56) for which enrollment is currently open, or for an available reserve capacity slot, in accordance with Chapter 1200-13-01-.31.4. Household size is based upon the ABD household composition Rule .06.5. Income Limitations: Income shall not exceed three hundred percent (300%) of the SSI Federal Benefit Rate for an individual. Parent-to-child deeming rules shall apply for a child except for those age 17 or older who meet institutional level of care, those enrolled prior to November 23, 2020, those who will be enrolled in ECF CHOICES Group 7 (Intensive Behavioral Family Supports), and those transitioning from ECF CHOICES Group 7 to ECF CHOICES Group 4 (Essential Family Supports) as defined in TennCare 1115 Demonstration Waiver III.6. Resource Limitations: Resources shall not exceed $2,000.00 for an individual. Parent-to-child deeming rules shall apply for a child except for those age 17 or older who meet institutional level of care, those enrolled prior to November 23, 2020, those who will be enrolled in ECF CHOICES Group 7 (Intensive Behavioral Family Supports), and those transitioning from ECF CHOICES Group 7 to ECF CHOICES Group 4 (Essential Family Supports) as defined in TennCare 1115 Demonstration Waiver III.7. Effective Date: Eligibility begins on the date all eligibility requirements are met.8. Special Asset Rules: See Paragraph (5)(h).9. Transfer of Assets: See Paragraph (5)(i).10. Penalty for Transfer of Assets: See Paragraph (5)(j).11. Undue Hardship: See Paragraph (5)(k).12. Patient Liability: See Paragraph (5)(l).13. Resource Assessment and CSRMA: See Paragraph (5)(m).(b) Interim ECF CHOICES At-Risk Group. 1. Definition: See Rule .02.2. Technical Eligibility Requirements: See Rule .04.3. Special Eligibility Requirements: To gain eligibility in this category, applicants must: (i) Not otherwise be eligible in a TennCare Medicaid category that confers LTSS benefits.(ii) Have an Intellectual Disability manifested before eighteen (18) years of age or a developmental disability manifested before twenty-two (22) years of age, as specified in T.C.A. § 33-1-101.(iii) Be in one of the defined target populations specified in Chapter 1200-1301-.31.(iv) Be At-Risk for Institutionalization, as defined in Chapter 1200-13-01-.02.(v) Qualify for an available slot in an ECF CHOICES Group defined at 1 20013-01-.02(56) for which enrollment is currently open, or for an available reserve capacity slot, in accordance with Chapter 1200-13-01-.31.(vi) Receive ECF CHOICES.4. Household size is based upon the ABD household composition Rule .06.5. Income Limitations: Income shall not exceed three hundred percent (300%) of the SSI Federal Benefit Rate for an individual. Parent-to-child deeming rules shall apply.6. Resource Limitations: Resources shall not exceed $2,000.00 for an individual. Parent-to-child deeming rules shall apply.7. Effective Date: Eligibility begins on the date all eligibility requirements are met.8. New enrollment into the Interim ECF CHOICES At-Risk Group closed upon implementation of Phase 2 of ECF CHOICES. Individuals enrolled in the Interim ECF CHOICES At-Risk Group prior to implementation of Phase 2 may remain enrolled in the interim group as long as they continue to meet the eligibility requirements and remain continuously enrolled in the interim group.9. Special Asset Rules: See Paragraph (5)(h).10. Transfer of Assets: See Paragraph (5)(i).11. Penalty for Transfer of Assets: See Paragraph (5)(j).12. Undue Hardship: See Paragraph (5)(k).13. Patient Liability: See Paragraph (5)(l).14. Resource Assessment and CSRMA: See Paragraph (5)(m).(c) ECF CHOICES At-Risk Group. 1. Definition: See Rule .02.2. Technical Eligibility Requirements: See Rule .04.3. Special Eligibility Requirements: To gain eligibility in this category, applicants must: (i) Not otherwise be eligible in a Medicaid category that confers LTSS benefits.(ii) Have an Intellectual Disability manifested before eighteen (18) years of age or a developmental disability manifested before twenty-two (22) years of age, as specified in T.C.A. § 33-1-101.(iii) Be in one of the defined target populations specified in Chapter 1200-1301-.31.(iv) Be At-Risk for Institutionalization, as defined in Chapter 1200-13-01-.02.(v) Qualify for an available slot in an ECF CHOICES Group defined at 1 20013-01-.02(56) for which enrollment is currently open, or for an available reserve capacity slot, in accordance with Chapter 1200-13-01-.31.(vi) Receive ECF CHOICES.4. Household size is based upon the ABD household composition Rule .06.5. Income Limitations: Income must be at or below 150% of the FPL for an individual. Parent-to-child deeming rules shall apply.6. Resource Limitations: Resources shall not exceed $2,000.00 for an individual. Parent-to-child deeming rules shall apply.7. Effective Date: Eligibility begins on the date all eligibility criteria are met.8. Special Asset Rules: See Paragraph (5)(h).9. Transfer of Assets: See Paragraph (5)(i).10. Penalty for Transfer of Assets: See Paragraph (5)(j).11. Undue Hardship: See Paragraph (5)(k).12. Patient Liability: See Paragraph (5)(l).13. Resource Assessment and CSRMA: See Paragraph (5)(m).(d) ECF CHOICES Working Disabled Group. 1. Definition: See Rule .02.2. Technical Eligibility Requirements: See Rule .04.3. Special Eligibility Requirements: To gain eligibility in this category, applicants must: (i) Not otherwise be eligible in a TennCare Medicaid category that confers LTSS benefits.(ii) Have an Intellectual Disability manifested before eighteen (18) years of age or a Developmental Disability manifested before twenty-two (22) years of age, as specified in T.C.A. § 33-1-101.(iii) Be in one of the defined target populations specified in Chapter 1200-1301-.31.(iv) Meet Nursing Facility Level of Care (NF LOC) or be At Risk for Institutionalization, as defined in Chapter 1200-13-01-.02.(v) Be working and would be eligible for SSI if their Earned Income was disregarded.(vi) Qualify for an available slot in an ECF CHOICES Group defined at 1 20013-01-.02(56) for which enrollment is currently open, or for an available reserve capacity slot, in accordance with Chapter 1200-13-01-.31.(vii) Receive ECF CHOICES.4. Household size is based upon the ABD household composition Rule .06.5. Income Limitations: Two separate income tests apply:(i) Income must be at or below 250% of the FPL for an individual. Parent-to-child deeming rules shall apply for a child except for those age 17 or older who meet institutional level of care, those enrolled prior to November 23, 2020, those who will be enrolled in ECF CHOICES Group 7 (Intensive Behavioral Family Supports), and those transitioning from ECF CHOICES Group 7 to ECF CHOICES Group 4 (Essential Family Supports) as defined in TennCare 1115 Demonstration Waiver III.(ii) Income must be less than the SSI Federal Benefit Rate after the applicant's earned income is disregarded. (I) Parent-to-child deeming rules and spouse-to-spouse deeming rules shall apply.(II) When spouse-to-spouse income deeming occurs, the applicant's income is compared against the SSI Federal Benefit Rate for a couple.6. Resource Limitations: Resources shall not exceed $2,000.00 for an individual. Parent-to-child deeming rules shall apply for a child except for those age 17 or older who meet institutional level of care, those enrolled prior to November 23, 2020, those who will be enrolled in ECF CHOICES Group 7 (Intensive Behavioral Family Supports), and those transitioning from ECF CHOICES Group 7 to ECF CHOICES Group 4 (Essential Family Supports) as defined in TennCare 1115 Demonstration Waiver III.7. Effective Date: Eligibility begins on the date all eligibility criteria are met.8. Special Asset Rules: See Paragraph (5)(h).9. Transfer of Assets: See Paragraph (5)(i).10. Penalty for Transfer of Assets: See Paragraph (5)(j).11. Undue Hardship: See Paragraph (5)(k).12. Patient Liability: See Paragraph (5)(l).13. Resource Assessment and CSRMA: See Paragraph (5)(m).(7) Medicare Savings Programs. (a) QMB.1. Definition: See Rule .02.2. Eligibility for this program is not eligibility for Medicaid coverage. An individual eligible for QMB is eligible for TennCare Buy-in of his Medicare premiums, and payment of Medicare coinsurance and deductibles.3. Technical Requirements: See Rule .04.4. Household size is based upon the ABD household composition Rule .06.5. Income Limitations: At or below one hundred percent (100%) of the FPL.6. Resource Limitations: Limits for an individual and couple as determined by CMS.7. Effective Date: First day of the month following the month in which the application is approved.(b) SLMB.1. Definition: See Rule .02.2. Eligibility for this program is not eligibility for Medicaid coverage. An individual eligible for SLMB is eligible for TennCare Buy-in of his Medicare Part B premiums.3. Technical Requirements: See Rule .04.4. Household size is based upon the ABD household composition Rule .06.5. Income Limitations: Over one hundred percent (100%) but less than one hundred twenty percent (120%) of the FPL.6. Resource Limitations: Limits for an individual and couple as determined by CMS.7. Effective Date: Eligibility begins on the Application File Date, according to Rule .05, or the date all eligibility requirements are met, whichever is later.(c) QI1.1. Definition: See Rule .02.2. Eligibility for this program is not eligibility for Medicaid coverage. An individual eligible for QI1 is eligible for TennCare Buy-in of his Medicare Part B premiums, pursuant to State allocation of federal funds. The individual may not be receiving TennCare Medicaid.3. Technical Requirements: See Rule .04.4. Household size is based upon the ABD household composition Rule .06.5. Income Limitations: Over one hundred twenty percent (120%) but less than one hundred thirty-five percent (135%) of FPL.6. Resource Limitations: Limits for an individual and couple as determined by CMS.7. Effective Date: Eligibility begins on the Application File Date, according to Rule .05, or the date all eligibility requirements are met, whichever is later.(d) QDWI.1. Definition: See Rule .02.2. Eligibility for this program is not eligibility for Medicaid coverage. An individual eligible for QDWI is eligible for TennCare Buy-in of his Medicare Part A premiums, but not for Part B premiums.3. Technical Requirements: See Rule .04.4. Special Eligibility Requirements: An individual must be under age sixty-five (65), have a disabling impairment as determined by the SSA, and be eligible to enroll in Medicare Part A but no longer entitled to free Medicare Part A due to substantial gainful activity.5. Household size is based upon the ABD household composition Rule .06.6. Income Limitations: Two hundred percent (200%) of FPL.7. Resource Limitations: Resources not exceeding twice the maximum for SSI for an individual or a couple, as applicable.8. Effective Date: Eligibility begins on the Application File Date, according to Rule .05, or the date all eligibility requirements are met, whichever is later.(8) Other. (a) Medically Needy Children and Pregnant Women.1. Definition: See Rule .02.2. Technical Requirements: See Rule .04.3. Special Eligibility Requirements: Applicants for the Medically Needy Pregnant Woman category must be pregnant at the time of application. Applicants for the Child Medically Needy category must be under age twenty-one (21).4. Household size is based upon the AFDC-Related household composition information set out in Rule .06.5. Income Limitations: Household income must be less than or equal to the MNIS, based on household size. When household income exceeds the MNIS, based on household size, the individual must meet a spenddown obligation as outlined in the State Plan. See Rule .06.6. Resource Limitations: Medically Needy applicants are permitted to retain resources not to exceed $2,000.00 for an individual, $3,000.00 for two individuals and an additional $100.00 is added per additional individual. See Rule .06.7. 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.8. Other: Pregnant women enrolled in the Medically Needy program shall receive continuous coverage through twelve (12) months postpartum, regardless of income changes.(b) Breast and Cervical Cancer Category of Eligibility.1. Definition: See Rule .02.2. Technical Requirements: See Rule .04.3. Special Eligibility Requirements:(i) Individuals must be younger than age sixty-five (65) and must lack health insurance that will cover treatment for breast and/or cervical cancer. Once third party coverage of cancer has been exhausted, the applicant will be considered to no longer have health insurance.(ii) Individuals must first be screened and approved by the Department of Health's BCSP.(iii) Individuals must be actively undergoing treatment for breast or cervical cancer. A Treatment Plan Form signed by the applicant's physician must be submitted to TennCare. Individuals who are determined to require only routine monitoring services for a precancerous breast or cervical condition are not considered to need treatment for purposes of this section. Surveillance after treatment of cancer (breast or cervical) will not qualify as treatment for purposes of this section.4. Income Limitations: Income cannot exceed two hundred fifty percent (250%) of the FPL, as determined by the Department of Health through its BCSP.5. Resource Limitations: None.6. 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.(c) Presumptive Breast or Cervical Cancer. 1. Definition: See Rule .02.2. Technical Requirements: See Rule .04.3. Special Eligibility Requirements:(i) Individual must be determined to be presumptively eligible by the Department of Health.(ii) Individual must be younger than age sixty-five (65) and must lack access to health insurance that will cover treatment for breast and/or cervical cancer.(iii) The presumptive eligibility period will last either until the end of the month following the month of application or determination of a full Medicaid application, as defined in 42 U.S.C. § 1396r-1b.4. Income Limitations: Income cannot exceed two hundred fifty percent (250%) of the FPL, as determined by the Department of Health through its BCSP program.5. Resource Limitations: None.6. Effective Date of Eligibility: The date eligibility is determined by the Tennessee Department of Health.(d) Payment for Emergency Medical Services. 1. Definition: See Rule .02.2. Technical Requirements: See Rule .04. Individuals must meet eligibility requirements for a Medicaid category except for citizenship and enumeration.3. Special Eligibility Requirements: Individuals who meet all eligibility criteria except citizenship and immigration status for the following TennCare categories of eligibility: (ii) Infants and Children Under Age 19;(iv) Child or Qualified Pregnant Woman Medically Needy.4. Individuals in one of the above categories may qualify for payment for emergency medical services in which the individual has a medical condition, including labor and delivery, manifested by acute symptoms of sufficient severity which, if not attended to immediately, could reasonably be expected to result in:(i) Placing the patient's health in serious jeopardy;(ii) Severe impairment to bodily functions: or(iii) Serious dysfunction of any bodily organ or part.5. Household size is based upon the appropriate TennCare category for which the enrollee is seeking coverage.6. Income Limitations: Must meet financial criteria of one of the respective TennCare categories (Caretaker Relative, Infants and Children Under Age 19, TennCare Pregnant Woman, or Child or Qualified Pregnant Woman Medically Needy).7. Resource Limitations: If an individual would be otherwise eligible for a Medically Needy category except for citizenship or immigration status, then the individual's resource limits are identical to those found in Rule .06, AFDC-Related Financial Determinations. If an individual would be otherwise eligible for a MAGI category except for citizenship or immigration status, then the individual's resources are not considered.8. Effective Date of Eligibility: Eligibility will not begin prior to the date of admission, nor will coverage begin prior to the date of application, and will be limited to the length of time required to stabilize the emergent episode, as defined at 42 C.F.R. § 440.255. Only the services involved in the emergency itself will be reimbursed and coverage is only provided for the single episode of care.(9) Katie Beckett Program-related Eligibility Groups.(a) Katie Beckett Group Part A. 1. Definition: See Rule .02.2. Technical Requirements: See Rule .04.3. Special Eligibility Requirements:(i) Individual must be younger than eighteen (18) years of age.(ii) Individual must meet the medical level of care requirements according to Rule 1200-13-01-.11.(iii) Individual must not be financially eligible for any other category of TennCare Medicaid or TennCare Standard.(iv) Third Party Liability (TPL).(I) Katie Beckett Group Part A enrollees shall be covered by either employer-sponsored insurance or private insurance, at all times. The employer-sponsored insurance or private insurance plans must include minimum essential coverage, as defined by 45 CFR 156.110(a).(II) If an eligible child attests to having TPL at the time of application, a notice requesting proof of TPL and the amount of the monthly TPL premium will be sent to the child. The child will have twenty (20) days from the date of the notice requesting proof of TPL and the amount of monthly TPL premiums to provide the requested information. If the requested information is not provided in a timely manner, the application will be denied for failure to respond.(III) If an eligible child does not have TPL at the time of application, the child will be enrolled in Katie Beckett Group Part A and will be required to submit proof of TPL and the amount of the monthly TPL premiums.I. The timeline for submitting proof of TPL will be as follows:A. Katie Beckett Group Part A enrollees who are enrolled on or before October 1 will have until January 15 of the immediately following calendar year to submit proof of TPL.B. Katie Beckett Group Part A enrollees who are enrolled between October 2 and December 31 will have until January 15 of the second following calendar year to submit proof of TPL.II. Failure to timely submit proof of TPL.A. Enrollees who fail to submit proof of TPL in accordance with the timelines provided in Subitem I. will receive an ex parte review of eligibility for other categories of TennCare Medicaid.B. If the ex parte review does not result in enrollment in another category of eligibility, the enrollee will be sent a questionnaire to determine if the enrollee' s circumstances have changed since the last review that would result in eligibility for other categories of TennCare Medicaid. The questionnaire must be returned within twenty (20) days from the date of the questionnaire.C. If the enrollee does not timely return the questionnaire or if the answers provided on the questionnaire do not result in enrollment in another category of eligibility, the enrollee will be sent a notice of termination informing the enrollee that Katie Beckett Group Part A coverage will be terminated twenty (20) days from the date of the termination notice if proof of TPL is not submitted prior to the date of termination.(IV) Calculating an eligible child's portion of monthly TPL premiums.I. The eligible child's portion of the family's monthly TPL premium is calculated by dividing the total amount of the family's monthly TPL premium by the number of individuals covered by the TPL.II. If a parent of the eligible child is required to purchase TPL in order for the eligible child to have TPL coverage, the parent's portion of the monthly TPL premium will be included in the child's portion of the TPL when calculating the Katie Beckett Group Part A premium.(V) Katie Beckett Group Part A enrollees must report any changes in TPL within ten (10) days of the change. Changes in TPL that must be reported include, but are not limited to: II. Change of TPL provider; orIII. Change in monthly TPL premium.(VI) Loss of TPL. I. If a Katie Beckett Group Part A enrollee loses TPL coverage and notifies TennCare, the enrollee will receive a notice requiring proof of new TPL. The enrollee will have sixty (60) days from the date of notice to submit proof of the new TPL.II. If the enrollee does not submit proof of TPL within 60 days of the date of the notice, the enrollee will be sent a questionnaire to determine if the enrollee's circumstances have changed since the last review that would result in eligibility for other categories of TennCare Medicaid. The questionnaire must be returned within twenty (20) days from the date of the questionnaire.III. If the enrollee does not timely return the questionnaire or if the answers provided on the questionnaire do not result in enrollment in another category of eligibility, the enrollee will be sent a notice of termination informing the enrollee that Katie Beckett Group Part A benefits will be terminated twenty (20) days from the date of the termination notice if proof of the new TPL is not submitted prior to the date of termination.(VII) A Katie Becket Group Part A enrollee who did not have TPL at the time of application and is disenrolled from Katie Beckett Group Part A for failing to timely submit proof of TPL will be eligible to transition to Medicaid Diversion Group Part B if a Medicaid Diversion Group Part B slot is available.(VIII) Katie Beckett Group Part A Hardship Exception for Assistance with Premium Payments. I. If an eligible child applying for Katie Beckett Group Part A does not have TPL at the time of enrollment, the child may request assistance with premium payments through a hardship exception if the following hardship exception requirements are met: A. The cost of the eligible child's portion of all available employer-sponsored or private insurance exceeds five percent (5%) of the family's household income according to MAGI methodology; orB. The child's household income is less than four hundred percent (400%) of the FPL according to MAGI methodology and neither of the child's parents have access to employer-sponsored insurance.II. A hardship exception for assistance with premium payments shall not be available for an eligible child who has TPL at the time of enrollment, even if such coverage is later lost and new TPL coverage must be obtained.III. Assistance with premium payments is limited to the lesser of the amount by which the child's portion of the family's monthly TPL premium exceeds the child's Katie Beckett Group Part A premium, as detailed below, or the lowest cost silver level child only plan in the highest rating region in Tennessee offered through the Federally Facilitated Marketplace. The amount of TPL premium assistance may be appealed within forty (40) days of the date of the notice.IV. The denial of a request for a hardship exception for assistance with premium payments may be appealed within forty (40) days of the date of the denial notice.V. The loss of assistance with premium payments resulting from a change in an enrollee's TPL may be appealed within forty (40) days of the date of the assistance with premium payments termination notice. If the termination of assistance with premium payments is appealed within twenty (20) days, the assistance with premium payments will continue until the conclusion of the appeal process.(v) Katie Beckett Group Part A Premiums. (I) Households with income above one hundred fifty percent (150%) of the FPL according to MAGI methodology will be required to pay a monthly premium through automatic electronic bank drafts. The amount of the premium will be based on a sliding scale. As set out in the table below, the family's FPL percentage is determined based on their household income and household size according to MAGI methodology, and the amount of the monthly premium for each applicable FPL range is set to the percentage of the income of a household size of two. Household Income (MAGI) | Premium % of income for a household size of two | Monthly Premium |
>150% - 250% FPL | 1.5% | $25 |
>250% - 300% FPL | 2.5% | $75 |
>300% - 400% FPL | 3% | $125 |
>400% - 500 % FPL | 4% | $225 |
>500% FPL - No limit | 5% | $350 + $70 for every 100% above 500% FPL |
(II) Katie Beckett Group Part A premiums, as described in the above table, will be reduced by the costs associated with the eligible child's portion of the family's monthly TPL premiums. If the total amount of the eligible child's portion of the family's TPL premium is more than the eligible child's monthly Katie Beckett Group Part A premium, the child will not have Katie Beckett Group Part A premium obligations. See Subpart (iv) above for calculating the eligible child's portion of the family's monthly TPL premium payment.(III) Initial enrollment shall not occur until the first month's Katie Beckett Group Part A premium has been paid in full and electronic automatic bank draft arrangements have been made for subsequent months unless the eligible child is not required to pay the monthly Katie Beckett Group Part A premium.(IV) If the first month's Katie Beckett Group Part A premium is not paid in full within sixty (60) days of the date of the notice detailing the amount of the monthly premium obligation, the application will be denied.I. If a timely appeal is filed, the Katie Beckett Group Part A program slot will be held until the conclusion of the appeal process.II. If a timely appeal is not filed, the Katie Beckett Group Part A program slot will be released and a new application for Katie Beckett Group Part A will be required.(V) Continuous enrollment in Katie Beckett Group Part A is contingent on timely payments of the monthly Katie Beckett Group Part A premium unless the eligible child does not have Katie Beckett Group Part A premium obligations.(VI) If a Katie Beckett Group Part A enrollee is required to pay Katie Beckett Group Part A premiums after previously not having Katie Beckett Group Part A premium obligations, the enrollee will have sixty (60) days from the date of the notice detailing the amount of the monthly premium obligation to pay the first month's Katie Beckett Group Part A premium in full and set up electronic automatic bank draft arrangements.(VII) Once enrolled, if the Katie Beckett Group Part A premium payment is more than thirty (30) days in arrears, enrollees will be sent a notice of suspension informing the enrollee that Katie Beckett Group Part A benefits will be suspended twenty (20) days from the date of the suspension notice if premium payments are not paid in full prior to the date of suspension. If suspended, Katie Beckett Group Part A program benefits will return to active status retroactive to the date they were suspended if: I. Past due premium payments are paid in full while the enrollee is in suspended status; orII. Benefits were suspended as the result of administrative error.(VIII) If any part of a Katie Beckett Group Part A premium payment is more than sixty (60) days in arrears, enrollees will be sent a notice of termination informing the enrollee that Katie Beckett Group Part A benefits will be terminated twenty (20) days from the date of the termination notice if past due Katie Beckett Group Part A premium payments are not paid in full prior to the date of termination. If the outstanding premium amounts owed are paid in full at any point prior to the effective date of termination, program benefits will return to active status retroactive to the date they were suspended. A Katie Becket Group Part A enrollee who is terminated from Katie Beckett Group Part A for failing to pay the monthly Katie Beckett Group Part A premium will be eligible to transition to Medicaid Diversion Group Part B if a Medicaid Diversion Group Part B slot is available.(IX) Once enrolled in Katie Beckett Group Part A, increases in the household income of an enrollee for Katie Beckett Group Part A premium purposes will not need to be reported until the annual renewal process in accordance with Rule .09. Enrollee income changes must be reported within ten (10) days of the occurrence in accordance with Rule .03(2)(a).(X) If a Katie Beckett Group Part A enrollee reports a change in the household income that results in a change in the Katie Beckett Group Part A premium, the enrollee will receive a notice informing the enrollee of the new Katie Beckett Group Part A premium payment amount.(vi) Eligibility and enrollment into Katie Beckett Group Part A is contingent upon a slot being available in accordance with Chapter 1200-13-01.4. Eligibility will be based upon a household size of one (1).5. Income Limitations: Income shall not exceed three hundred percent (300%) of the SSI Federal Benefit Rate for an individual. Parent-to-child deeming rules shall not apply.6. Resource Limitations: Resources shall not exceed two thousand dollars ($2,000.00) for an individual. Parent-to-child deeming rules shall not apply.7. Effective Date of Eligibility: Eligibility begins on the date that the first month's Katie Beckett Group Part A premium is paid in full and electronic automatic bank draft arrangements have been made for subsequent months. If an eligible child is not required to pay Katie Beckett Group Part A premiums, eligibility begins on the date the individual is determined to be eligible.8. Upon turning age eighteen (18), individuals enrolled in Katie Beckett Group Part A may remain enrolled in Katie Beckett Group Part A for up to twelve (12) months following the enrollee's eighteenth (18th) birthday if an application for SSI is pending or in appeal status.(b) Medicaid Diversion Group Part B. 1. Definition: See Rule .02.2. Technical Requirements: See Rule .04.3. Special Eligibility Requirements:(i) Individual must be younger than eighteen (18) years of age.(ii) Individual must meet the medical level of care requirements according to Rule 1200-13-01-.11.(iii) Individual must not be financially eligible for any other category of TennCare.(iv) Eligibility and enrollment into Medicaid Diversion Group Part B is contingent upon a slot being available in accordance with Chapter 120013-01.4. Eligibility will be based upon a household size of one (1).5. Income Limitations: Income shall not exceed three hundred percent (300%) of the SSI Federal Benefit Rate for an individual. Parent-to-child deeming rules shall not apply.6. Resource Limitations: Resources shall not exceed two thousand dollars ($2,000.00) for an individual. Parent-to-child deeming rules shall not apply.7. 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.8. Medicaid Diversion Group Part B will be administered by the Department of Intellectual and Developmental Disabilities (DIDD).(c) Continued Eligibility Group Part C.1. Definition: See Rule .022. Technical Requirements: See Rule .043. Special Eligibility Requirements:(i) Individual who was validly enrolled in TennCare Medicaid and is losing eligibility for TennCare Medicaid and who is younger than eighteen (18) years of age.(ii) Individual must meet the medical level of care requirements according to Rule 1200-13-01-.11.(iii) Individual would be eligible to enroll in Katie Beckett Group Part A if a Katie Beckett Group Part A slot was available.(iv) No Katie Beckett Group Part A slots are available.4. Eligibility will be based upon a household size of one (1).5. Income Limitations: Income shall not exceed three hundred percent (300%) of the SSI Federal Benefit Rate for an individual. Parent-to-child deeming rules shall not apply.6. Resource Limitations: Resources shall not exceed $2,000.00 for an individual. Parent-to-child deeming rules shall not apply.7. If an enrollee is terminated from the Continued Eligibility Group Part C, the individual will have to reapply for Katie Beckett Group Part A with enrollment in Katie Beckett Group Part A being limited to slot availability.8. If an enrollee is terminated from the Continued Eligibility Group Part C because of an administrative error, the individual will be eligible to re-enroll in the Continued Eligibility Group Part C.9. Upon turning age eighteen (18), Continued Eligibility Group Part C enrollees may remain enrolled in the Continued Eligibility Group Part C for up to twelve (12) months following the eighteenth (18th) birthday if an application for SSI is pending or in appeal status.Tenn. Comp. R. & Regs. 1200-13-20-.08
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. Emergency rules filed November 20, 2020; effective through May 19, 2021. Amendments filed February 17, 2021; effective May 18, 2021. 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, 71-5-112, 715-117, and 71-5-164 and TennCare II/III Section 1115(a) Medicaid Demonstration Waiver Extension.