Tenn. Comp. R. & Regs. 1200-13-20-.09 - REDETERMINATION AND TERMINATION
(1) Redetermination
of eligibility for TennCare Medical Assistance.
(a) Redetermination or renewal is the process
of verifying whether an enrollee continues to meet the eligibility requirements
of a particular TennCare program.
(b) An enrollee must have eligibility
redetermined once every twelve (12) months, and no more frequently than once
every twelve (12) months according to
42 C.F.R. §
435.916, absent a waiver from CMS.
(c) Enrollees eligible for TennCare Medicaid
as a result of being eligible for SSI benefits shall follow the Redetermination
requirements of the SSA. Once SSI benefits are terminated, these enrollees will
be reviewed by TennCare for eligibility in all other categories prior to
termination.
(d) An enrollee's
TennCare Medical Assistance eligibility shall be redetermined as required by
the appropriate category of Medical Assistance as described in this Rule,
unless otherwise agreed to by the Single State Agency and CMS. Prior to the
termination of TennCare Medical Assistance eligibility, eligibility will be
redetermined according to the following process:
1. TennCare will redetermine eligibility
prior to the expiration of the enrollee's current eligibility period.
2. TennCare will complete an ex parte review
of eligibility. A renewal packet will be issued when ex parte review does not
result in a finding of eligibility. TennCare Medical Assistance enrollees will
be given forty (40) days, inclusive of mail time, from the date the notice is
mailed to return the completed renewal packet to TennCare. The mail date will
be the date on the notice. The enrollee may provide information by the same
modes permitted for filing an application specified at Rule .05, or as
otherwise agreed to by the Single State Agency and CMS.
3. TennCare will provide assistance with
submitting a renewal form according to Rule .05.
4. TennCare will use the individual's
responses in the renewal packet to complete redetermination. TennCare will
request additional verification, as needed, to complete redetermination. The
request for additional information or verification will provide the enrollee
with twenty (20) days, inclusive of mail time, to submit the requested
information.
5. If TennCare is able
to renew eligibility in a TennCare Medical Assistance category based on
information known to TennCare, or information provided in the renewal packet,
and requested verifications, the agency will notify the enrollee and enroll him
in the appropriate category.
6.
Enrollees who respond to the renewal form within the forty (40) day period
shall retain their eligibility (subject to any changes in covered services
generally applicable to enrollees in their Medical Assistance category) while
TennCare reviews their eligibility for open Medical Assistance categories. If
TennCare determines that the enrollee is eligible for a TennCare Medical
Assistance category, the agency will notify the individual as follows:
(i) If TennCare determines that the enrollee
is eligible for an open TennCare Medicaid category, the agency will notify the
enrollee and he will be enrolled in the appropriate category. If the individual
is enrolled in a different TennCare Medicaid category of eligibility, the
previous category will be closed with no further notice to the
enrollee.
(ii) If TennCare
determines that the enrollee is eligible for a TennCare Standard category, the
agency will notify the enrollee and he will be enrolled in the appropriate
category. Notification of enrollment into TennCare Standard will include
notification of the denial of TennCare Medicaid eligibility.
(iii) If TennCare determines that the
enrollee is eligible for CoverKids, the agency will notify the enrollee and he
will be enrolled into the CoverKids program. Notification of enrollment into
CoverKids will include the denial of TennCare Medicaid eligibility.
(iv) If TennCare determines that the enrollee
is eligible for MSP, the agency will notify the enrollee and he will be
enrolled into the appropriate MSP. If an individual is determined eligible for
MSP and ineligible for TennCare Medicaid, notification of enrollment in an MSP
will include notification of the denial of TennCare Medicaid. Notification of
enrollment into SLMB or QI1 will include notification of the denial of QMB
eligibility.
7. If an
enrollee provides some but not all of the necessary information to TennCare to
determine his eligibility for open Medical Assistance categories during the
forty (40) day period following the mailing of the renewal packet, TennCare
will request additional information or verification. The request for additional
information or verification will provide the enrollee with twenty (20) days,
inclusive of mail time, to submit the requested information.
8. Enrollees who do not respond to the
renewal packet within forty (40) days, or enrollees who do not respond to a
request for additional information or verification within twenty (20) days from
the request for additional information or verification, will be sent a notice
of termination informing the enrollee that coverage will be terminated twenty
(20) days from the date of the termination notice.
9. If TennCare makes a determination that the
enrollee is not eligible for any open Medical Assistance categories, the
enrollee will be sent a notice of termination informing the enrollee that
coverage will be terminated twenty (20) days from the date of the termination
notice.
10. Enrollees who respond
to the additional information or verification request after the requisite time
period specified in those notices but before the date of termination shall
retain their eligibility while TennCare reviews their eligibility.
11. Individuals may provide the renewal
packet, or additional information and verifications specified in the request
for additional information and verification notice, up to ninety (90) days
after termination of eligibility. Renewal packets or additional information
received during the ninety (90) day reconsideration period will be processed
without requiring a new application. Individuals terminated for failure to
respond and subsequently determined eligible during the ninety (90) day
reconsideration period will have eligibility reinstated as of the date of
termination.
(e) An
individual who has been determined eligible for TennCare Medicaid under the
rules for BCC shall annually recertify eligibility in terms of continuation of
active treatment, address, and access to health insurance. If the individual is
found to no longer be eligible through this review, the individual will be
reviewed using the redetermination process set forth in this
paragraph.
(f) An individual who
has been determined eligible for TennCare under the rules for Katie Beckett
Group Part A, Medicaid Diversion Group Part B, or Continued Eligibility Group
Part C will be required to verify continued eligibility annually. If the
individual is found to no longer be eligible through this review, the
individual will be reviewed using the redetermination process set forth in this
paragraph.
(2)
Termination of TennCare Medical Assistance.
(a) TennCare will send termination notices to
all enrollees being terminated pursuant to state and federal law who are not
determined to be eligible for any open category of Medical Assistance or who
receive a change in benefits or services.
(b) Termination notices will be sent twenty
(20) days in advance of the date the coverage will be terminated. Termination
notices will be sent two (2) days in advance of the date coverage will be
prospectively terminated when an enrollee requests termination. Termination
notices will be sent to the TennCare address of record.
(c) Termination notices will provide
enrollees forty (40) days from the date of the notice to appeal the termination
and will inform enrollees how they may request a hearing. Appeals will be
processed by TennCare in compliance with Chapter 1200-13-19.
(d) TennCare will reconsider eligibility
after termination in compliance with
42 C.F.R. §
435.916(a)(3)(iii).
(e) Enrollees with a physical health problem,
mental health problem, learning problem or a disability will be given the
opportunity to request additional assistance for their appeal. Enrollees with
limited English proficiency will have the opportunity to request translation
assistance for their appeal.
Notes
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.
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