This chapter governs all administrative hearings conducted
for the purpose of reviewing eligibility determinations for the following
categories which use the MAGI income methodology: Children Under 19, Pregnant
Women, Caretaker Relatives, CHIP - Children and Pregnancy
(CoverKids/HealthyTNBabies). Eligibility determination appeals for any other
eligibility category will not be governed by this chapter. This chapter will
govern all delay hearings for all eligibility categories. These rules preempt
any other TennCare Rules to the extent that they are in conflict with this
chapter.
(1) The Tennessee Medical
Assistance Act of 1968 and Executive Order Number 23, dated October 19, 1999,
designate the Tennessee Department of Finance and Administration as the single
state agency for purposes of administering Title XIX of the Social Security Act
(Medicaid).
(2) The CoverKids Act
of 2006 authorizes the Tennessee Department of Finance and Administration to
establish and administer a program to provide health care coverage to uninsured
children under Title XXI of the Social Security Act (State Children's Health
Insurance Program).
(3) Titles XIX
and XXI of the Social Security Act, TennCare II Medicaid Section 1115
Demonstration Waiver, and
42 CFR Subpart E require the designated state agency
to provide for appeals and fair hearings concerning eligibility determinations
for applicants and recipients of assistance and services provided through the
programs.
(4) The Commissioner of
the Department of Finance and Administration has placed responsibility for
eligibility determination appeal hearings in the Division of Health Care
Finance and Administration (HCFA), except as specifically delegated to the
Department of Human Services. HCFA employs Administrative Judges vested with
full authority to conduct the hearing process, including authority to schedule
and conduct a hearing; administer oaths; issue subpoenas; rule upon offers of
proof; regulate the course of the hearing; set the time and place for continued
hearings; enter an Initial Order; rule on petitions for reconsideration; and
perform duties or actions that are necessary for the fair and timely management
of the administrative hearing process.
(5) Tennessee Code Annotated §
71-5-112 requires any hearing
concerning matters of eligibility for medical assistance to be conducted under
the Tennessee Uniform Administrative Procedures Act.
(6) Any procedural matter not specifically
addressed by these rules is to be resolved by consulting the following
authorities in the order listed: the Tennessee Uniform Administrative
Procedures Act (UAPA), the Uniform Rules of Procedure For Hearing Contested
Cases Before State Administrative Agencies (UAPA Rules), and the Tennessee
Rules of Civil Procedure (TRCP).