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

Tenn. Comp. R. & Regs. 1200-13-20-.09

Emergency rule filed June 16, 2016; effective through December 13, 2016. New rules filed September 14, 2016; effective December 13, 2016. Amendment filed February 12, 2018; effective May 13, 2018. 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.