Tenn. Comp. R. & Regs. 1240-03-03-.06 - INCOME LIMITATIONS FOR THE MEDICALLY NEEDY AND STANDARD SPEND DOWN

(1) In medically needy cases for pregnant women and children under age twenty-one (21), countable income is determined by using the Families First/AFDC cash assistance program's income definitions and policies. Refer to Families First/AFDC income rules 1240-01-50-.08, 1240-01-50-.10 through 1240-01-50-.15, 1240-01-50-.16, and 1240-01-50-.17 through 1240-01-50-.19, with the following exceptions:

(a) The earned income disregard of thirty dollars ($30.00) plus one-third (1/3) of the remainder is granted in a medically needy case only if the applicant has received Families First/AFDC in at least one (1) of the last four (4) months. In such a situation the disregard is applied only for a four (4) month period.

(b) The maximum cap or gross income of one hundred eighty-five percent (185%) of the Families First/AFDC need standard does not apply to medically needy due to the spend-down provision.

(2) Persons applying as Medically Needy must have a deduction for incurred cost of medical/health insurance premiums, deductibles and co-payments.

(a) Costs incurred for medical insurance premiums, co-payments and deductibles; and

(b) Expenses incurred for necessary medical and remedial services that are recognized under State law, but not included in the State plan for medical assistance.

(3) Determination of countable income of an individual or family.

(a) The countable income of an individual or family, once determined, is tested against the following standard, depending upon the number of individuals for whom application is made:

Size of Family	Monthly
1	Two hundred forty-one dollars ($241) (effective July 1, 1999)
2 and above	One hundred thirty-three and one-third percent (133 1/3%) of the maximum money payment which could be made to a family of the same size under Families First/AFDC

(Refer to Families First Handbook for payment levels and ratably reduced standard of need.)

(4) Countable medical or remedial expenses for determination of spenddown eligibility.

(a) Medical and remedial expenses that remain unpaid, have not been written off by the health care provider, and that are the client's responsibility, may, pursuant to this paragraph (4), be applied to any excess income to reduce income in order to qualify for eligibility in the spenddown category.

(b) For new applicants during open enrollment periods as announced by the Bureau of TennCare or persons currently Exceptionally Eligible who did not meet spenddown criteria in order to qualify during their last eligibility determination, the following medical/remedial expenses will be counted toward the reduction of income in the Standard Spend Down coverage group:

1. Expenses incurred during the month of application, whether paid or unpaid;

2. Expenses paid during the month of application, regardless of when such bills were incurred;

3. Expenses incurred during the three (3) calendar months prior to the month of application whether paid or unpaid.

(i) Expenses paid during the three (3) calendar months prior to the month of application will not be counted unless such expenses were also incurred during those three (3) calendar months.

(ii) Any expenses incurred before the three (3) calendar months prior to the month of application will not be counted unless payment is made on those expenses during the month of application, in which case only the amount paid during the month of application is counted.

(iii) When any new applicants apply again after their first year of eligibility, countable medical or remedial expenses will be limited to the expenses incurred or paid as described in parts 1, 2 and 3(i) and (ii) to expenses for the new month of application and three (3) calendar months prior to the new month of application, plus any unpaid expenses that were previously verified and documented as part of this new spenddown process, i.e., only those expenses incurred or paid during the month of application and expenses incurred during the three (3) calendar months prior to that month of application. Verified expenses can be carried over as long as the individual remains continuously eligible, the expenses remain unpaid and are not written off by the provider. If the individual loses eligibility at any point, or if the individual ever qualifies as Exceptionally Eligible in the future, the carryover of unpaid medical expenses ends, and the individual is limited to the expenses listed in subparagraph (b)1, 2 and 3(i) and (ii).

(iv) When an Exceptionally Eligible individual re-applies, no carryover of expenses is permitted because spenddown criteria were not required to qualify as Exceptionally Eligible, and the individual is limited to the expenses listed in (b)1, 2, and 3(i) and (ii). If thereafter, the individual does have to meet spenddown criteria to re-qualify, then, for the continuous eligibility period thereafter, applicable expenses that were verified and documented in any eligibility determination, after the period in which the person qualified as Exceptionally Eligible, that remain unpaid will be counted. Any medical/remedial expenses that otherwise may have been used to qualify for medically needy coverage under spenddown criteria in the period prior to the period in which the individual did not have to meet spenddown criteria to qualify for medically needy coverage cannot be carried over in order to establish eligibility.

(c) For current medically needy eligibles, the following medical/remedial expenses will be counted toward the reduction of income in medically needy coverage groups:

1. Expenses incurred during the month of application, whether paid or unpaid;

2. Expenses paid during the month of application, regardless of when such bills were incurred;

3. Expenses incurred during the three (3) calendar months prior to the month of application; whether paid or unpaid.

(i) Expenses paid during the three (3) calendar months prior to the month of application will not be counted unless such bills were also incurred during those three (3) calendar months.

(ii) Any expenses incurred before the three (3) calendar months prior to the month of application will not be counted unless:

(I) Payment is made on those expenses during the month of application, in which case only the amount paid during the month of application is counted; or

(II) All of the following are satisfied:

I. Those expenses were previously verified in order to meet spenddown criteria;

II. The individual has remained continuously eligible in a spenddown category since that time;

III. The individual met a spenddown criteria during each period of eligibility in order to qualify; and

IV. The expenses remain unpaid and have not been written off by the provider.

A. When the circumstances of subitem (II)IV exist, the carryover that has not been previously deducted from income for purposes of qualifying for spenddown can be applied. The carryover expense can include an unused portion or an entirely unpaid expense.

B. Only in cases of individuals who are currently eligible, expenses incurred before the three (3) calendar months prior to the initial month of application may be carried over, but only unpaid expenses that were previously verified and documented in the DHS eligibility data system as part of the spenddown process will be counted. Expenses that had not been provided earlier to determine eligibility cannot be counted.

C. To be counted, the expenses must have remained unpaid, and only the portions not used earlier to qualify under spenddown criteria are counted.

4. Not all expenses incurred during the entire continuous eligibility period will be counted towards spenddown eligibility. Only expenses identified in (c)1, 2 and 3 above including qualifying carryover expenses from earlier spenddown determinations will be counted.

5. When a gap in eligibility occurs or there is any period of eligibility in which the individual has no excess income, the individual must re-qualify under subparagraph (b) above.

(5) Patient liability for institutionalized individuals whose gross income exceeds the categorical Medicaid income cap and the individual has established a qualified income trust will be determined by using the deductions listed within rule 1240-03-03-.04(2)(d) and by comparing the remainder to the Medicaid reimbursement rate for the long-term care being provided.

Notes

Tenn. Comp. R. & Regs. 1240-03-03-.06

Repeal and new rule filed June 14, 1976; effective July 14, 1976. Amendment filed September 15, 1977; effective October 14, 1977. Amendment filed June 9, 1981; effective October 5, 1981. Repeal and new rule filed August 17, 1982; effective September 16, 1982. Amendment filed September 4, 1984; effective October 4, 1984. Amendment filed May 23, 1986; effective August 12, 1986. Amendment filed July 23, 1986; effective October 29, 1986. Amendment filed May 8, 1987; effective August 29, 1987. Amendment filed March 7, 1988; effective June 29, 1988. Amendment filed April 8, 1988; effective July 27, 1988. Amendment filed August 9, 1989; effective September 23, 1989. Amendment filed May 1, 1991; effective June 15, 1991. Amendment filed August 17, 1992; effective October 8, 1992. Amendment filed December 30, 1993; effective March 15, 1994. Amendment filed April 23, 1997; effective July 7, 1997. Amendment filed October 26, 2001; effective January 9, 2002. Public necessity rule filed January 24, 2008; effective through July 7, 2008. Amendments filed April 22, 2008; effective July 6, 2008.

Authority: T.C.A. §§ 4-5-201 et seq, 4-5-202, 71-1-105(12) 71-5-102, 71-5-106 , 71-5-109; 42 U.S.C. §§ 1396 et seq, 42 USC § 1396r-5 and 42 U.S.C. § 1315, 42 U.S.C. §1396a(a)(10)(A)(ii)(I); 20 C.F.R. § 416.1205(c), 42 C.F.R. 435.210, 435.300, and 435.301; 42 USCA §1396a(a)(17)(D) and (q); 42 C.F.R. §§435.831, 435.832, 435.845, and 435.1007; PL 98-369§2611, PL 99-272§§ 9501 and 9506, PL 100-360§303; and TennCare II Medicaid Section 1115 Demonstration Waiver.