Tenn. Comp. R. & Regs. 1200-13-20-.05 - GENERAL APPLICATION REQUIREMENTS

(1) Right to apply.

(a) Any individual shall have the opportunity to apply for Medical Assistance without delay.

(b) Information about the TennCare or CoverKids program shall be provided to any individual requesting it pursuant to 42 C.F.R. § 435.905.

(c) Applications may be filed by the applicant, an individual listed in Rule .05(3)(b), his Authorized Representative or someone acting responsibly for him. See 42 C.F.R. § 435.923.

(d) Proof of eligibility is not required of an individual prior to filing an application.

(e) The right to file an application shall not be denied to any individual even if it is apparent that eligibility for Medical Assistance does not exist.

(2) Rights and responsibilities.

(a) By applying for Medical Assistance, an applicant grants permission and authorizes release of information to TennCare, or its designee, to investigate any and all information provided, or any information not provided if it could affect eligibility, to determine Medical Assistance eligibility; and if approved, what cost sharing, if any, may be required of the applicant. Information may be verified through, but not limited to, the following sources:

1. The United States Internal Revenue Service (IRS);

2. State income tax records for Tennessee or any other State where income is earned;

3. The Tennessee Department of Labor and Workforce Development, and other Employment Security offices within any State where the applicant may have received wages or been employed;

4. Credit bureaus;

5. Insurance companies; or,

6. Any other governmental agency or public or private source of information where such information may impact an applicant's eligibility or cost sharing requirements for the TennCare or CoverKids Program. The Federal Data Services Hub, or "electronic service" referred to in 42 C.F.R. § 435.949, is an example of such an information source.

(b) It is a felony offense, pursuant to T.C.A. § 71-5-2601, to apply for Medical Assistance under false means or to help anyone obtain Medical Assistance under false means.

(c) By applying for Medical Assistance, an applicant agrees to provide information to TennCare, or its designee, about any third party coverage in which the applicant is enrolled.

(3) Submitting an application.

(a) TennCare will accept Valid Applications in compliance with 42 C.F.R. § 435.907 and, for CoverKids applicants, 42 C.F.R. § 457.330, or as otherwise agreed to by the Single State Agency and CMS.

(b) An application can be filed by one of the following individuals, as applicable:

1. Adult applicants or an adult who is in the applicant's household as defined in 42 C.F.R. § 435.603(f);

2. An adult who is in the applicant's family, as defined in the Internal Revenue Code at 26 U.S.C. § 36B(d)(1);

3. Applicants over age fourteen (14) but under age eighteen (18) who are emancipated or are considered sufficiently mature to make their own health care decisions;

4. A parent who has primary custody of a minor child;

5. Either parent of a minor child when custody is equally divided between legal parents;

6. The legal guardian or conservator;

7. An Authorized Representative;

8. If the applicant is a minor or incapacitated, someone acting responsibly for the applicant; or

9. A representative of the long term care facility where the individual resides.

(c) Applications received from Tennessee residents living out of state.

1. Applications filed for Tennessee residents who are temporarily out of state may be accepted.

2. The application of someone who is hospitalized in another state and planning to return to Tennessee when discharged may be processed in the usual manner.

(d) Out of state applicants.

1. Applications received from individuals residing in another state and not intending to reside in Tennessee will be denied.

2. Individuals who are in Tennessee for a temporary purpose, such as a visit, and who intend to return to their home out of state are not eligible for TennCare or CoverKids.

3. Applicants must always be given the right to submit an application if they wish to do so and receive a decision on their application.

(4) Assistance with submitting an application. TennCare is required to provide assistance to any individual seeking help with the application or redetermination process in person by Certified Application Counselors (CACs), over the phone, and online in a manner that is accessible to individuals with disabilities and those who have limited English proficiency. Assistance includes, but is not limited to, the following:

(a) Help with application or other TennCare form completion;

(b) Help with securing a representative, if needed, and/or allowing someone of the applicant's choice to assist with the application and renewal process; and

(c) Help in obtaining necessary information from third parties.

(5) Applications may be filed in any of the following ways:

(a) By mail.

1. Paper applications mailed to TennCare. The Application File Date for an application mailed to TennCare will be the date a Valid Application is received.

2. Paper applications mailed to the FFM. The Application File Date will be the date provided by the FFM.

(b) By phone.

1. Applicants may call TennCare to complete an application by phone. The Application File Date will be the date a Valid Application is completed telephonically.

2. The Application File Date for applications completed by phone through the FFM will be the date provided by the FFM.

(c) By fax. Paper applications may be faxed to TennCare. The Application File Date for applications faxed to TennCare will be the date a Valid Application is received.

(d) By online submission.

1. Applications may be submitted through TennCare's online portal. The Application File Date will be the date a Valid Application is submitted.

2. The Application File Date for applications filed through the FFM will be the date provided by the FFM, unless documentary evidence of an earlier application date exists.

(e) In person at any DHS county office.

1. The Application File Date for paper applications submitted to DHS will be the date of receipt of a Valid Application at DHS.

2. Applicants may use kiosks provided at DHS to submit online applications. Applicants may use phones provided at DHS offices to complete an application.

(f) Low Income Subsidy (LIS) applications through the SSA. The Application File Date will be the date provided by the SSA.

(6) Processing time. Eligibility will be timely determined in compliance with 42 C.F.R. § 435.912, or as otherwise agreed to by the Single State Agency and CMS.

(7) Retroactive Eligibility. TennCare will grant Retroactive Eligibility with Valid Applications for pregnant women (or during the sixty (60) day period beginning on the last day of the pregnancy), or children under age nineteen (19) as described in Section 1902(I)(4) of the Social Security Act (42 U.S.C.§ 1396a(l)(4)) who meet the retroactive eligibility requirements described in 42 C.F.R. § 435.915.

(8) Disposition.

(a) Eligibility is determined based on information contained on the Valid Application as well as information secured during the application process.

(b) All applications will be subject to one (1) of the following actions:

1. Approval. When all eligibility factors are met, the application is approved.

2. Denial. When one or more eligibility factor(s) is not met, the application is denied.

(i) Death is not an appropriate reason to deny an application. If the applicant dies before a final eligibility determination is made, the application process must be continued to completion.

(ii) Applicants who do not respond to requests for verifications by the State in a timely manner will be denied for failure to respond to such requests.

(iii) Applicants who do not provide sufficient information in response to requests for verifications by the State will be denied.

(c) Withdrawal. When an applicant decides to withdraw his request for assistance during the application process, it is not necessary to complete any remaining verification and evaluation.

Notes

Tenn. Comp. R. & Regs. 1200-13-20-.05

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.