Determination of Eligibility for Medical Assistance

1. Law
2. Tennessee Code
3. Welfare
4. Programs and Services for Poor Persons
5. Medical Assistance Act
6. Determination of Eligibility for Medical Assistance

1. 1. The departments of health and human services, as may be designated by the governor, shall make the determination of eligibility under this part, subject to approval of the finance, ways and means, and the health and welfare committees of the senate, the health committee of the house of representatives, and the committee of the house of representatives having oversight over TennCare. Such determination of eligibility may be accomplished through contractual agreement with agencies of the federal government. Eligibility for assistance shall be determined in a manner that will ensure that medical assistance is provided, within the limits of available resources subject to federal financial participation, to all persons who, although ineligible for supplementary security income (SSI), complied under Title XVI of the Social Security Act (42 U.S.C. § 1381 et seq.), or are medically needy.
   2. 1. A notice that awards medicaid benefits shall include the following statement:

         “A person with both medicare and medicaid does not usually need other health insurance. Did you buy a medicare supplement policy after November 4, 1991? If so, you can have the insurance company put your policy and your payments on hold. The insurance company can do this for up to twenty-four (24) months while you are on medicaid. If you lose medicaid during the twenty-four-month period, you can get your policy back.

         “To put your policy on hold, contact your insurance company within ninety (90) days of when you get medicaid. To get your policy back, you must tell your insurance company within ninety (90) days after you lose medicaid.”

      2. A notice that terminates medicaid benefits shall include the following statement:

         “Did you have medicare supplement insurance that you put on hold while you had medicaid? You may be able to get your policy back if you have put it on hold less than two (2) years ago. Contact your insurance company within ninety (90) days after you lose medicaid. Tell the insurance company that you want your policy reinstated.”

2. In determining the eligibility of an individual for benefits under this chapter, resources that have been previously owned and transferred by the individual, or such individual's spouse, shall be treated in a manner consistent with Title XIX of the Social Security Act.
3. Any transaction described in subsection (b) shall be presumed to have been for the purpose of establishing eligibility for benefits or assistance under this part, unless such individual or eligible spouse furnishes convincing evidence to establish that the transaction was exclusively for some other purpose.
4. For purposes of subsection (b), the value of such a resource or interest shall be the fair market value of such resource or interest at the time it was sold or given away, less the amount of compensation received for such resource or interest, if any.
5. In the event that any resource, or interest in any resource, is given away or sold for less than fair market value by a person holding a power of attorney by the owner of the resource or interest, such resource or interest shall not be counted as a resource to the owner of the property pursuant to subsections (b)-(d) under the following circumstances:
   1. The power of attorney was not executed for the purpose of establishing or continuing medicaid eligibility;
   2. The owner of the property has, at the time of the transfer, neither actual nor constructive knowledge of the transfer or is unable because of mental or physical incapacity to take reasonable and necessary steps to prevent such sale or transfer.
6. If any resource or interest in any resource is given away or sold for less than fair market value by a person holding a power of attorney by the owner of such resource, the sale or gift shall be set aside by a court of competent jurisdiction as being in defraud of the state upon motion of the state of Tennessee or of any party representing the owner of the resource, unless the person holding the power of attorney proves by a preponderance of the evidence that the sale or gift was exclusively for some other purpose than the establishment or continuance of medicaid eligibility.
7. In addition to the requirements of subsection (f), the person exercising the power of attorney and the person to whom the resource is given or sold for less than fair market value shall be jointly and severally liable to the state of Tennessee for any costs incurred by it in providing medicaid benefits to the owner of the resource, until such time as the conveyance is set aside, for any costs, including attorney fees, court costs, and any other related expenses, incurred by it in having the conveyance set aside, and for any losses incurred as a result of any damage, destruction, expenditure, waste, transfer of the resources or other act of the persons involved that diminishes the value of the resource. Such liability shall be limited to the actual value of the resource.
8. In the event that a person otherwise eligible for medicaid has filed an action in court to set aside a transfer for less than value because of fraud, duress, trick or otherwise, such person shall be or shall remain eligible, or both, and the state of Tennessee shall have recourse under subsections (f) and (g) to set aside the transfer and recover.
9. In addition to the other categories of eligibility under this section, there shall be a category of medical assistance eligibility for those children who:
   1. 1. Were born after September 30, 1967;
      2. Are eighteen (18) years of age or younger; and
      3. Are in intact families that meet the TANF income and resource requirements; or
   2. As provided in Title IV of the Social Security Act (42 U.S.C. § 601 et seq.), have been determined to be a child with special needs, for whom there is in effect an adoption assistance agreement between the department of children's services and an adoptive parent or parents, and who the department of children's services has determined cannot be placed with an adoptive parent or parents without medical assistance because such child has special needs for medical, mental health, or rehabilitative care.
10. Subsections (b)-(j) shall not limit the ability of the state to extend medical assistance to persons who are medically needy pursuant to any federal waiver received by the state that waives any or all of the provisions of Title XIX or pursuant to any other federal law as adopted by amendment to the required Title XIX state plan.
11. Effective January 1, 1998, if the actual enrollment of non-previously enrolled children under eighteen (18) years of age that began on April 1, 1997, has not reached seventy-five percent (75%) of anticipated enrollment level of fifty thousand (50,000) children, the commissioner of health shall offer enrollment in the Title XIX waiver program, TennCare, to children under eighteen (18) years of age whose family income is below two hundred percent (200%) of the federal poverty level schedule in effect for calculation of TennCare premiums. Such offer of enrollment in the TennCare program shall be made in accordance with TennCare promulgated rules and regulations. It is the legislative intent that this section be implemented only to the extent that it is determined to be consistent with the terms, conditions and eligibility criteria of the TennCare waiver as approved by the United States department of health and human services and that state and federal funding is available for such purpose.
12. Beginning January 1, 2003, the bureau of TennCare or its designee shall determine eligibility for TennCare on an annual basis as follows:
    1. All non-medicaid eligible TennCare enrollees will have the responsibility to complete an eligibility process each year; in the absence of reapplication and completion of the process, coverage will expire;
    2. Upon notification by the bureau of TennCare, the enrollee must submit application for continuation of eligibility within ninety (90) days; once an application has been timely submitted, the enrollee must provide all required documentation to verify continued eligibility in accordance with TennCare rules and regulations;
    3. Notification to the enrollee is presumed when a notice is mailed to the last known address;
    4. Lack of receipt of the notification does not excuse the responsibility of the enrollee to submit an application and provide documentation for continuation of eligibility as required by TennCare rules and regulations if the enrollee has changed addresses and failed to notify the bureau of TennCare or its designee; and
    5. Failure of the enrollee to contact the bureau of TennCare or its designee concerning a change in address relieves the bureau of responsibility for contacting the enrollee.
13. To the extent permitted by federal law, the state may impose a reasonable fee for costs of eligibility determinations for applicants applying for medical assistance as part of the medically eligible expansion population under the TennCare waiver.
14. In the TennCare waiver expansion population, except for persons medically eligible as uninsurable persons, enrollment shall not be permitted for individuals from households with incomes of greater than two hundred fifty percent (250%) of federal poverty levels.
15. Except as may be required by federal law or the TennCare waiver, no person shall be eligible to receive TennCare benefits, except employee health insurance subsidy payments, as part of the TennCare waiver expansion population if such person is enrolled in a health insurance plan as such coverage is defined in TennCare rules and regulations, or if such person is eligible for participation in medicare or group health insurance offered through an employer or family member's employer, or COBRA coverage.
16. All determinations of eligibility for persons medically eligible as uninsurable in the TennCare waiver's expansion population shall be made on the basis of health conditions that prevent the person from obtaining health insurance. Such a determination will be based upon a review of medical records and information in accordance with TennCare rules and regulations.
17. To the extent permitted by the terms of relevant court orders and decrees, any applicable federal waiver under Title XIX of the federal Social Security Act or any other federal law, the bureau of TennCare may not remove persons from eligibility for or participation in medical assistance provided pursuant to this chapter for reasons relating to restricting eligibility or enrollment for fiscal or other reasons that are not required by federal law until the bureau has complied with both of the following:
    1. The bureau has verified at the time of application the validity of the social security number of every person enrolled in the medical assistance program provided pursuant to this chapter with appropriate federal databases in order to determine whether persons who are not lawful residents of the United States are present in the program, or are otherwise fraudulent applicants; and
    2. Removed from the program all such ineligible persons who are current recipients in the program but are not lawful residents of the United States, or are otherwise fraudulent applicants.
18. 1. An individual who is an inmate of a public institution shall have eligibility for medical assistance suspended but not terminated during periods of actual incarceration.
    2. An individual who is an inmate of a public institution shall be eligible for temporary reinstatement of medical assistance for care received outside of a jail or correctional facility in a hospital or other health care facility for more than twenty-four (24) hours.
    3. A public institution may make efforts to establish eligibility for or renew assistance for such individuals prior to their release from the public institution.

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