1200-13-20-.02 - [Effective until 5/19/2021]DEFINITIONS AND ACRONYMS

1200-13-20-.02. [Effective until 5/19/2021]DEFINITIONS AND ACRONYMS

(1) Access to Health Insurance (TennCare). The opportunity an individual has to obtain group health insurance as defined elsewhere in these rules. If a person could have enrolled in work-related or other group health insurance during an employer's or group's open enrollment period and chose not to enroll (or had the choice made for him by a family member) that person shall not be considered to lack access to insurance upon closure of the open enrollment period. Neither the cost of an insurance policy or health plan nor the fact that an insurance policy is not as comprehensive as that of the TennCare Program shall be considered in determining eligibility to enroll in any TennCare category where being uninsured is an eligibility prerequisite. Access to health insurance through the Federally Facilitated Marketplace (FFM) shall not constitute "access to insurance" for purposes of eligibility for TennCare.

(2) Achieving a Better Life Experience (ABLE) Account. An account established under 26 U.S.C.A. § 529A. ABLE accounts or 529A accounts are tax-advantaged savings accounts for individuals with disabilities that are established under a qualified ABLE program.

(3) Active SSI Recipient. An individual who has been found eligible to receive SSI benefits by the SSA.

(4) Aged. An individual age sixty-five (65) or older.

(5) Aid to Families With Dependent Children (AFDC). The name of the cash assistance program for families and children prior to the passage of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) in July 1996.

(6) Annuities. Contracts or agreements that, in exchange for a lump sum payment or series of payments, provide for the payment of income at regular intervals, e.g., monthly, quarterly, annually, etc. Annuities establish a source of income for a future period and are often used in retirement planning.

(7) Applicant. An individual who is seeking an eligibility determination for himself through an application submission or a transfer from another agency or insurance affordability program. For purposes of this Chapter, applicant also includes an individual who is seeking an eligibility determination for himself through an application for Medicare Savings Programs (MSP).

(8) Application. The single, streamlined form developed for use for all insurance affordability programs, as required by 42 C.F.R. § 435.907(b).

(9) Application File Date. See Rule .05(5).

(10) Authorized Representative. An Authorized Representative as defined at 42 C.F.R. § 435.923.

(11) Blind. An individual who is determined to be blind by the SSA.

(12) Breast and Cervical Cancer (BCC). The Medicaid eligibility category defined at Section 1902(aa) of the Social Security Act (42 U.S.C. § 1396a(aa)). This eligibility category covers individuals who have been found to have breast or cervical cancer through the National Breast and Cervical Cancer Early Detection Program, who are under age sixty-five (65), do not otherwise have creditable coverage (including current enrollment in Medicaid), as the term is used under the Health Insurance Portability and Accountability Act (HIPAA) § 2701(c) of the PHS Act (42 U.S.C. § 300gg(c)), are not otherwise eligible for Medicaid or receiving TennCare Standard, and who are currently undergoing treatment for breast or cervical cancer.

(13) Bureau of TennCare (Bureau). The agency within the Division of TennCare which directly administers the TennCare program.

(14) Caretaker Relative. A relative of a dependent child by blood, adoption, or marriage with whom the child lives, assumes primary responsibility for the child's care, and is one of the following:

(a) The child's father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece; or

(b) The spouse of such caretaker relative, even after the marriage is terminated by death or divorce.

(15) Centers for Medicare & Medicaid Services (CMS). See definition in Rule 1200-13-13-.01.

(16) Children's Health Insurance Program (CHIP). Established by Title XXI of the Social Security Act and administratively included in the Division of TennCare.

(17) CHOICES. TennCare CHOICES in Long-Term Services and Supports, as defined in Rule 1200-13-01-.02.

(18) Community Spouse. The legal spouse of an institutionalized individual. A community spouse may not reside in a medical institution or nursing facility.

(19) Completed Application. An application that meets the following criteria:

(a) All required fields have been completed;

(b) Is signed and dated by the applicant, the applicant's parent or guardian, an individual acting on behalf of the applicant, or an authorized representative;

(c) Includes all supporting documentation required by the Bureau to determine TennCare, Medicare Savings Program or CoverKids eligibility, including technical and financial requirements as set out in this Chapter; and

(d) If the application is for the TennCare Standard Medically Eligible category, it includes all supporting documentation required to prove TennCare Standard medical eligibility as set out in this Chapter.

(20) Comprehensive Aggregate Cap Waiver. See definition in Tennessee's 1915(c) Home and Community Based Services Waiver.

(21) Continued Eligibility Group Part C. See definition in Rule 1200-13-01-.02.

(22) Core Medicaid Population. Individuals eligible under Title XIX of the Social Security Act, 42 U.S.C. §§ 1396, et seq., with the exception of the following groups: active SSI recipients who are receiving benefits as determined by the SSA; individuals eligible for emergency services as an undocumented or ineligible alien; individuals in a presumptive eligibility period; and children in DCS custody, including DCS children who meet the criteria for immediate eligibility and those receiving adoption assistance payments.

(23) CoverKids. The Children's Health Insurance Program (CHIP) in Tennessee under T.C.A. § 71-3-1101.

(24) CoverKids Pregnant Women (formerly referred to as "CoverKids Pregnant Women/Unborn Children"). Provides coverage for the unborn children of pregnant women with no source of coverage, who meet the CoverKids eligibility requirements.

(25) Deemed Newborn. An individual eligible in a Medicaid category authorized by Section 1902(e)(4) of the Social Security Act (42 U.S.C. § 1396a(e)(4)) and 42 C.F.R. § 435.117. A child is eligible for Medicaid in this category from birth until the child's first birthday without application if, on the date of the child's birth, the child's mother was eligible for and received covered Medicaid services.

(26) Disabled. An individual who has been determined to be disabled by the SSA or meets conditions in Rule .08(5)(c).

(27) Disabled Adult Child (DAC). The Medicaid eligibility category defined in Section 1634(c) of the Social Security Act (42 U.S.C. § 1383c(c)).

(28) Division of TennCare. The Agency established within the Department of Finance and Administration to consolidate and administratively coordinate multiple health care programs, including the Bureau of TennCare and CoverKids.

(29) Effective Date. The first date of eligibility for purposes of health care services coverage and payment.

(30) Eligible. An individual who has been determined to meet the eligibility criteria for medical assistance under Tennessee's State Plan or in any Tennessee federal Medicaid waiver program approved by the Secretary of the HHS pursuant to Sections 1115 or 1915 of the Social Security Act or in the CoverKids program. (42 U.S.C. §§ 1315 or 1396n).

(31) Enrollee. An individual eligible for and enrolled in the TennCare program or in any Tennessee federal Medicaid waiver program approved by the Secretary of the HHS pursuant to Sections 1115 or 1915 of the Social Security Act or in the CoverKids program. (42 U.S.C. §§ 1315 or 1396n). For purposes of this Chapter, enrollee also includes individuals eligible for and enrolled in the Medicare Savings Programs (MSPs).

(32) Enrollment. The process by which a TennCare, CoverKids, or Medicare Savings Program eligible individual becomes enrolled in TennCare, CoverKids or a Medicare Savings Program.

(33) Exchange. A governmental agency or non-profit entity that meets the applicable Federal standards and makes Qualified Health Plans (QHPs), including TennCare and CoverKids, available to qualified individuals and/or qualified employers. Unless otherwise identified, this term includes an Exchange serving the individual market for qualified individuals and a Small Business Health Options Program (SHOP) serving the small group market for qualified employers, regardless of whether the Exchange is established and operated by a State (including a regional Exchange or subsidiary Exchange) or by the HHS.

(34) Extended Medicaid. Medicaid eligibility authorized for enrollees who lose Child Modified Adjusted Gross Income (MAGI) or Caretaker Relative MAGI eligibility due to increased receipt of spousal support, whose household income prior to losing eligibility was at or below the current Caretaker Relative MAGI income standard for three (3) of the six (6) months preceding the month of the increase in income.

(35) Families First (FF). Tennessee's Temporary Assistance for Needy Families (TANF) program.

(36) Federal Data Services Hub. An electronic service established by the HHS to facilitate sharing of data and other information between federal agencies, State agencies, and other entities involved in administering Insurance Affordability Programs.

(37) Federal Financial Participation (FFP). See definition in Rule 1200-13-13-.01.

(38) Federal Poverty Level (FPL). The poverty level established annually by HHS.

(39) Federally Facilitated Marketplace (FFM). See "Exchange."

(40) Financially Responsible Relatives (FRR). Principle of financial responsibility that exists between spouses and of parents to their children which is used in determining household composition, income counting and resource counting for certain Medicaid categories.

(41) Former Foster Care Children Under 26. The Medicaid eligibility category defined at Section 1902(a)(10)(A)(i)(IX) of the Social Security Act (42 U.S.C. § 1396a(a)(10)(A)(i)(IX)).

(42) Group Health Insurance. An employee benefit plan to the extent that the plan provides medical care to employees or their dependents (as defined under the terms of the plan) directly through an insurance reimbursement mechanism. This definition includes those types of health insurance found in the Health Insurance Portability and Accountability Act of 1996, as amended, definition of creditable coverage (with the exception that the 50-or-more participants criteria do not apply), which includes Medicare and TRICARE. Health insurance benefits obtained through COBRA are included in this definition. It also covers group health insurance available to an individual through membership in a professional organization or a school.

(43) Health Insurance (for CoverKids).

(a) Health insurance, for purposes of determining eligibility for CoverKids under this Chapter, shall mean:

1. Basic medical coverage (hospitalization plans);

2. Major medical insurance;

3. Comprehensive medical insurance;

4. Short-term medical policies;

5. Mini-medical plans;

6. High-deductible plans with health savings accounts; or

7. Other coverage including Medicare, TennCare, TRICARE, and employer-sponsored coverage.

(b) Health insurance, for purposes of determining eligibility for CoverKids under this Chapter, shall not include the following:

1. AccessTN;

2. Catastrophic health insurance plans that only provide medical services after satisfying a deductible in excess of $3, 000.00 (or the maximum allowed deductible for a health savings account plan);

3. Dental-only plans;

4. Vision-only plans;

5. Benefits provided by the U.S. Department of Veterans Affairs or the Indian Health Service.

6. Coverage under the State of Tennessee's Children's Special Services program; or

7. Medical insurance that is available to an enrollee pursuant either to the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 (29 U.S.C. §§ 1161, et seq.) and which the individual declined, or to T.C.A. §§ 56-7-2312, et seq., and which the individual declined.

(c) Consistent with 42 U.S.C. § 1397jj(b)(2)(B) and 42 C.F.R. §§ 457.301 and 457.310(c)(1)(ii), health insurance shall not include State-administered or other medical coverage offered by means of a family member's employment with a local education agency (LEA) if the LEA does not make more than a nominal contribution (as defined at 42 C.F.R. § 457.310(c)(1)(ii)) to the premium for the dependent, who is applying (or re-applying) for coverage through CoverKids.

(44) Health Insurance (for TennCare).

(a) Health insurance, for purposes of determining eligibility for TennCare under this Chapter, shall mean:

1. Any hospital or medical expense-incurred policy;

2. Medicare;

3. TRICARE;

4. COBRA;

5. Medicaid;

6. State health high-risk pool;

7. Nonprofit health care service plan contract;

8. Health maintenance organization (HMO) subscriber contracts;

9. Group Health Insurance;

10. Coverage available to an individual through membership in a professional organization or a school;

11. Coverage under a policy covering one individual or all members of a family under a single policy where the contract exists solely between the individual and the insurance company;

12. Policies listed in parts 1. through 11. which include any of the following are health insurance:

(i) The policy contains a type of benefit (such as mental health benefits) which has been completely exhausted;

(ii) The policy contains a type of benefit (such as pharmacy) for which an annual limitation has been reached; or

(iii) The policy has a specific exclusion or rider of non-coverage based on a specific prior existing condition or an existing condition or treatment of such a condition.

13. Any of the types of policies listed in this subparagraph will be considered Health Insurance even if one or more of the following circumstances exists:

(i) The policy contains fewer benefits than TennCare;

(ii) The policy costs more than TennCare; or

(iii) The policy is one the individual could have bought during a specified period of time (such as COBRA) but chose not to do so.

(b) Health insurance, for purposes of determining eligibility under these Rules, shall not mean:

1. Short term coverage;

2. Accident coverage;

3. Fixed indemnity insurance;

4. Long-term care insurance;

5. Disability income contracts;

6. Limited benefits policies as defined elsewhere in this Rule;

7. Credit insurance;

8. School-sponsored sports-related injury coverage;

9. Coverage issued as a supplement to liability insurance;

10. Automobile medical insurance;

11. Insurance under which benefits are payable with or without regard to fault and which are statutorily required to be contained in any liability insurance policy or equivalent self-insurance;

12. A medical care program of the Indian Health Services (IHS) or a tribal organization;

13. Benefits received through the U.S. Department of Veterans Affairs; or

14. Health care provided through a government clinic or program such as, but not limited to, vaccinations, flu shots, mammograms, and care or services received through a disease- or condition-specific program such as, but not limited to, the Ryan White CARE Act.

(45) Health Insurance Marketplace, also referred to as the "Marketplace", "Exchange" or "Federally Facilitated Marketplace". See "Exchange."

(46) Home and Community Based Services (HCBS). See definition in Rule 1200-13-01-.02.

(47) Hospital Presumptive Eligibility (HPE). Medicaid eligibility determined pursuant to 42 C.F.R. § 435.1110.

(48) Household Size. The number of individuals counted as members of an individual's household for purposes of determining eligibility for TennCare.

(49) Immediate Eligibility (for DCS children only). An arrangement whereby children in the custody of the State who are presumed to be TennCare-eligible may gain TennCare eligibility while their applications are being processed.

(50) Inactive SSI Enrollee. Individuals whose SSI cash benefits have been terminated by SSA and who remain eligible for TennCare until they have been reviewed for coverage in other eligibility categories. Inactive SSI enrollees are not eligible for CHOICES.

(51) Incarcerated. The state of being involuntarily confined in a local, State, or federal prison, jail, youth development center, or other penal or correctional facility, including the state of being on furlough from such facility.

(52) Incurred Medical Expense. The term used in Tennessee to refer to the methodology for deducting expenses incurred for necessary medical or remedial care for institutionalized individuals in the post-eligibility phase of income. Previously known as "Item D". See 42 C.F.R. §§ 435.725(c)(4), 435.726(c)(4) and 435.832(c)(4).

(53) Infants and Children Under Age 19. The Medicaid eligibility categories defined at Sections 1902(a)(10)(A)(i)(III), (IV), (VI), and (VII); 1902(a)(10)(A)(ii)(IV) and (IX); and 1931(b) and (d) of the Social Security Act. (42 U.S.C. §§ 1396a(a)(10)(A)(i)(III), (IV), (VI) and (VII); 1396a(a)(10)(A)(ii)(IV) and (IX); and 1396u-1(b) and (d)).

(54) Institutional Eligibility. The eligibility category defined at Section 1902(a)(10)(A)(ii)(V), (VI) and (VII) of the Social Security Act. (42 U.S.C. § 1396a(a)(10)(A)(ii)(V), (VI) and (VII)).

(55) Institutional Spouse. An institutionalized individual who is the legal spouse of a Community Spouse.

(56) Insurance Affordability Program. A program that is one of the following:

(a) TennCare.

(b) CoverKids.

(c) APTC/CSR for participation in a QHP available through the FFM.

(57) Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID). An institution described at 42 C.F.R. Part 483, Subpart I.

(58) Joint Custody. Legal custody of a child held simultaneously by two (2) or more caretaker relatives. The caretaker relatives must exercise care and control of the child.

(59) Katie Beckett Group Part A. See definition in Rule 1200-13-01-.02.

(60) Katie Beckett Program. See definition in Rule 1200-13-01-.02.

(61) Limited Benefits Policy. A policy of health coverage for a specific disease (e.g., cancer), or an accident occurring while engaged in a specified activity (e.g., school-based sports), or which provides for a cash benefit payable directly to the insured in the event of an accident or hospitalization (e.g., hospital indemnity).

(62) Long-Term Care. See "Long-Term Services and Supports" (LTSS).

(63) Long-Term Services and Supports (LTSS) Program. See definition in Rule 1200-13-01-.02.

(64) Marketplace. See "Exchange."

(65) Medicaid. The federal- and state-financed, state-run program of medical assistance pursuant to Title XIX of the Social Security Act. Medicaid eligibility in Tennessee is determined by TennCare. Tennessee residents determined eligible for SSI benefits by the Social Security Administration are also enrolled in Tennessee's TennCare Medicaid program.

(66) Medicaid Diversion Group Part B. See definition in Rule 1200-13-01-.02.

(67) Medicaid Income Cap (MIC). Three hundred percent (300%) of the SSI Federal Benefit Rate.

(68) Medicaid "Rollover" Enrollee. A TennCare Medicaid enrollee under the age of 19 who no longer meets eligibility requirements for Medicaid and who is afforded an opportunity to enroll in TennCare Standard according to the provisions of these Rules.

(69) Medical Assistance. All categories for which TennCare is authorized to make an eligibility determination, including Medicaid and MSP categories, CHIP, and categories granted under TennCare's Demonstration Agreement with CMS.

(70) Medically Needy. The Medicaid eligibility category described at Section 1902(a)(10)(C) of the Social Security Act (42 U.S.C. § 1396a(a)(10)(C)).

(71) Medically Needy Income Standard (MNIS). See definition at 42 C.F.R. § 435.811.

(72) Medicare. The program administered through the SSA pursuant to Title XVIII, available to most individuals upon attaining age sixty-five (65), to some disabled individuals under age sixty-five (65), and to some individuals that have End Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS), as determined by the SSA.

(73) Medicare Buy-In. The process by which TennCare "buys" Medicare beneficiaries into the Medicare program. The Medicare buy-in consists of paying for some or all of a beneficiary's Medicare premiums, deductibles, or coinsurance.

(74) Medicare Savings Program (MSP). One of the programs under which low-income Medicare beneficiaries can get assistance from Medicaid for paying for some or all of their Medicare premiums, deductibles or coinsurance. These programs include the Qualified Medicare Beneficiary (QMB) program, the Specified Low Income Medicare Beneficiary (SLMB) program, the Qualifying Individual (QI1) program and the Qualified Disabled and Working Individual (QDWI) program.

(75) Miller Trust. See "Qualified Income Trust."

(76) Modified Adjusted Gross Income (MAGI). See definition at 42 C.F.R. § 435.603(e).

(77) Nursing Facility (NF). See definition in Rule 1200-13-.01-.02.

(78) PACE Carryover Group. See definition in Rule 1200-13-01-.02.

(79) Patient Liability. See definition in Rule 1200-13-01-.02.

(80) Payment for Emergency Medical Services. Eligibility authorized by Section 1903(v) of the Social Security Act (42 U.S.C. § 1396b(v)).

(81) Personal Needs Allowance (PNA). A reasonable amount of money that is deducted by TennCare from the individual's funds pursuant to federal and State law and the Medicaid State Plan in the application of post-eligibility provisions and the calculation of Patient Liability for LTSS. The PNA is set aside for clothing and other personal needs of the individual while in the institution (Institutional PNA), and to also pay room, board and other living expenses in the community (Community PNA).

(82) Pickle Passalong. The eligibility category defined at 42 C.F.R. § 435.135.

(83) Pregnant Women. For purposes of the Medicaid program, the Medicaid eligibility category defined at Sections 1902(a)(10)(A)(i)(III), (IV) and (VII); 1902(a)(10)(A)(ii)(I), (IV), and (IX); and 1931(b) and (d) of the Social Security Act (42 U.S.C. §§ 1396a(a)(10)(A)(i)(III), (IV), and (VII); 1396a(a)(10)(A)(ii)(I), (IV) and (IX); and 1396u-1(b) and (d)); and 42 C.F.R. § 435.116.

(84) Presumptive Eligibility for Individuals with Breast or Cervical Cancer. Individuals presumed to be eligible for coverage under the Medicaid category authorized by Section 1902(aa) of the Social Security Act (42 U.S.C. § 1396a(aa)) based on a determination by the Tennessee Department of Health or other qualified entity.

(85) Presumptive Eligibility for Pregnant Women. Women presumed to be eligible for coverage in the category defined at Sections 1902(a)(10)(A)(i)(III), (IV) and (VII); 1902(a)(10)(A)(ii)(I), (IV) and (IX); and 1931(b) and (d) of the Social Security Act (42 U.S.C. §§ 1396a(a)(10)(A)(i)(III), (IV), and (VII); 1396a(a)(10)(A)(ii)(I), (IV) and (IX); and 1396u-1(b) and (d)); and in 42 C.F.R. § 435.1103 by the Tennessee Department of Health or other qualified entity.

(86) Program of All-Inclusive Care for the Elderly (PACE). See definition in Rule 1200-13-01-.02.

(87) Qualified Disabled and Working Individual (QDWI). An individual who is under age sixty-five (65), has lost free Medicare Part A coverage due to substantial gainful activity, has a disabling impairment, has the option to purchase Medicare Part A for an indefinite period of time, and for whom Medicaid pays the Medicare Part A premium, if income is not more than two hundred percent (200%) of the FPL and resources are not more than twice the SSI limit and is not otherwise eligible for Medicaid. Eligibility is authorized by Sections 1905(p)(3)(A)(i) and (s); and 1902(a)(10)(E)(ii) of the Social Security Act (42 U.S.C. §§ 1396d(p)(3)(A)(i) and (s); and 1396a(a)(10)(E)(ii)).

(88) Qualified Health Plan (QHP). See definition at 42 U.S.C. § 18021.

(89) Qualified Income Trust (QIT). The trust defined at 42 U.S.C. § 1396p(d)(4)(B).

(90) Qualified Long-Term Care Insurance Partnership Policy (LTCP). A long-term care insurance policy issued on or after October 1, 2008, that has been pre-certified by the Tennessee Department of Commerce and Insurance pursuant to Rule 0780-01-61 as:

(a) A policy that meets all applicable Tennessee Long Term Care Partnership requirements; or

(b) A policy that has been issued in another Partnership State and which is covered under a reciprocal agreement between that State and the State of Tennessee.

(91) Qualified Medicare Beneficiary (QMB). An individual who is entitled to Medicare Part A and for whom Medicaid pays the Medicare Part A and Part B premium, coinsurance and deductible for Medicare-covered services, and whose income is not more than one hundred percent (100%) of the FPL. Eligibility is authorized by Sections 1905(p) and 1902(a)(10)(E)(i) of the Social Security Act (42 U.S.C. §§ 1396d(p) and 1396a(a)(10)(E)(i)).

(92) Qualifying Individual 1 (QI1). An individual who is entitled to Medicare Part A, for whom Medicaid pays Medicare Part B premiums on a first-come, first-served basis, and who has income at least one hundred and twenty percent (120%) of the FPL but less than one hundred and thirty-five percent (135%) of the FPL. Individuals are not enrolled in TennCare Medicaid or TennCare Standard. Eligibility is authorized by Section 1902(a)(10)(E)(iv) of the Social Security Act (42 U.S.C. § 1396a(a)(10)(E)(iv)) and 42 U.S.C. § 1396u-3.

(93) Qualifying Medical Condition. A medical condition included on a list of conditions established by TennCare which will render a qualified uninsured applicant medically eligible.

(94) Redetermination. The process by which TennCare evaluates the ongoing eligibility status of TennCare Medicaid enrollees who are considered a part of the Core Medicaid Population, as well as TennCare Standard, CoverKids, Katie Beckett Group Part A, and Continued Eligibility Group Part C enrollees. This is a periodic process that is conducted at specified intervals. The process is conducted according to TennCare's, or its designee's, policies and procedures and is also referred to as "Renewal." The Medicaid Diversion Group Part B, including redetermination of eligibility, will be administered by the Department of Intellectual and Developmental Disabilities (DIDD).

(95) Renewal. See "Redetermination."

(96) Responsible Party(ies). The following individuals, who are representatives and/or relatives of recipients of medical assistance who are not financially eligible to receive benefits: parents, spouses, children, and guardians; as defined at T.C.A. § 71-5-103.

(97) Single State Agency (CoverKids and TennCare). The Department of Finance and Administration.

(98) Specified Low-Income Medicare Beneficiary (SLMB). An individual who is eligible for Medicare Part A and for whom Medicaid pays Medicare Part B premiums, if income is at least one hundred percent (100%) but less than one hundred twenty percent (120%) of the FPL. Eligibility is authorized by Sections 1905(p)(3)(A)(ii) and 1902(a)(10)(E)(iii) of the Social Security Act (42 U.S.C. §§ 1396d(p)(3)(A)(ii) and 1396a(a)(10)(E)(iii)).

(99) Spenddown. The process by which excess income is utilized for recognized medical expenses until it is depleted, which results in a determination of eligibility if all other eligibility factors are met for the Medically Needy categories.

(100) SSI - Related Groups. Individuals who have been found eligible in one of the following categories:

(a) Disabled Adult Children (DAC).

(b) Pickle Passalong.

(c) Widow/Widower.

(101) Standard Child Medically Eligible. An uninsured child under age nineteen (19) who is losing eligibility for Medicaid or currently enrolled in TennCare Standard, whose household income is two hundred and eleven percent (211%) of the FPL or higher, who does not have access to health insurance, and who has been determined medically eligible according to these Rules.

(102) Standard Child Uninsured. The TennCare Demonstration category defined as including individuals in the following groups:

(a) Uninsured children under age nineteen (19) who are losing eligibility for Medicaid, or are currently enrolled in TennCare Standard, who have household incomes below two hundred and eleven percent (211%) of the FPL, and who do not have access to health insurance; or

(b) Uninsured children under age nineteen (19) who have been continuously enrolled in TennCare Standard since December 31, 2001, who have family incomes below two hundred and eleven percent (211%) of the FPL, and who have not purchased insurance even if they have access to it. This is a "grandfathered" eligibility category. When an individual loses eligibility in this category, he will not be able to re-enroll in it.

(103) Student. A child under age twenty-one (21), unless otherwise specified in this Chapter, who is:

(a) Eligible for and attending grades kindergarten through twelve at a State-approved elementary or secondary school, or a course of vocational or technical training, or equivalent instruction from a homebound teacher; or

(b) Eligible for and attending a college or university.

1. Full-time student means enrollment in at least twelve (12) credit hours per semester.

2. Part-time student means enrollment in at least six (6) but less than twelve (12) credit hours per semester.

(c) Student status is retained during official school vacations and breaks if the conditions or requirements prior to the vacation or break were met, and the student plans to return after the break.

(d) Regularly attending school, except when circumstances beyond the student's control justify a reduced credit load or attendance, means:

1. College or university, at least 8 hours per week (semester or quarter system);

2. Grades 7-12, including home-schooled, at least 12 hours per week;

3. Training course preparing for a paying job, at least 12 hours per week or 15 hours per week if the course involves shop practice; or

4. Homebound courses given by a school grades 7-12, college, university or government agency when the student must stay home due to a disability and has a home visitor or tutor from school who directs the studying or training.

(e) Individuals participating in apprenticeships, correspondence courses, other courses of home study and rehabilitation programs other than academic, institutional, vocational or technical training are excluded from this definition of student for purposes of this Chapter.

(104) Supplemental Security Income (SSI). A federal income supplement program funded by general tax revenues and is designed to help aged, blind and disabled individuals who have little or no income. Applications for SSI benefits are filed at the Social Security office. Individuals who are eligible for SSI are automatically entitled to Medicaid (42 U.S.C. §§ 1382, et seq.).

(105) Temporary Assistance for Needy Families (TANF). A program created by the PRWORA in 1996. TANF became effective in July 1996 and replaced what was then commonly known as the AFDC program. The name given to Tennessee's TANF program is Families First.

(106) TennCare. The program administered by the Single State agency as designated by the State and CMS pursuant to Title XIX of the Social Security Act and the Section 1115 Research and Demonstration waiver granted to the State of Tennessee; also, the name of the Division within the Department of Finance and Administration which includes the Bureau of TennCare and CoverKids; and, the name of the Bureau which directly administers the program.

(107) TennCare CHOICES in Long-Term Services and Supports. The program described in Rule 1200-13-01-.05. CHOICES is a benefit package available to TennCare enrollees who are eligible in the Institutional Medicaid category or who are active SSI enrollees and who meet the requirements of the program set out in Chapter 1200-13-01.

(108) TennCare Medicaid. That part of the TennCare program which covers individuals eligible for Medicaid under Tennessee's Title XIX State Plan for Medical Assistance. The following individuals are eligible for TennCare Medicaid:

(a) Tennessee residents determined to be eligible for Medicaid according to this Chapter.

(b) Individuals who qualify as dually eligible for Medicare and Medicaid are enrolled in TennCare Medicaid.

(c) A Tennessee resident who is an uninsured individual, under age sixty-five (65), a US citizen or qualified alien, is not eligible for any other category of Medicaid, and has been diagnosed as the result of a screening at a Centers for Disease Control and Prevention (CDC) site with breast or cervical cancer, including pre-cancerous conditions.

(d) Tennessee residents determined eligible for SSI benefits and TennCare Medicaid by the SSA are automatically enrolled in TennCare Medicaid.

(109) TennCare Standard. That part of the TennCare Program which provides health coverage for Tennessee residents who are not eligible for Medicaid and who meet the eligibility criteria found in this Chapter.

(110) Termination. The discontinuance of an enrollee's coverage under the Medical Assistance programs.

(111) Title IV-E. The section of the Social Security Act under which grants are made to States for implementation of foster care and adoption assistance programs. Eligibility is authorized by Section 1902(a)(10)(A)(i)(I) of the Social Security Act (42 U.S.C. § 1396a(a)(10)(A)(i)(I)), 42 C.F.R. § 435.115, and 42 C.F.R. § 435.145.

(112) Transitional Medicaid. Medicaid authorized for enrollees who lose Child MAGI or Caretaker Relative MAGI eligibility due to increased earnings and whose household income prior to losing eligibility was at or below the current Caretaker Relative MAGI income standard for three (3) of the six (6) months immediately preceding the month eligibility is lost.

(113) Uninsured. Any individual who does not have health insurance directly or indirectly through another family member, or who does not have access to group health insurance. For purposes of the Medicaid eligibility category of women under age 65 requiring treatment for breast or cervical cancer, "uninsured" shall mean any individual who does not have health insurance or access to health insurance which covers treatment of breast or cervical cancer.

(114) Valid Application. The single streamlined application form for all insurance affordability programs. It must include contact information and be signed by the Applicant, a Responsible Party, or the Authorized Representative.

(115) Widow/Widower. The eligibility category defined at 42 C.F.R. § 435.138.

(116) ACRONYMS. Following is a list of the acronyms used in this Chapter.

(a) ABD - Aged, Blind or Disabled

(b) AFDC - Aid to Families with Dependent Children

(c) APTC - Advanced Premium Tax Credit

(d) APTC/CSR - Advanced Premium Tax Credit/Cost Sharing Reductions

(e) BCC - Breast and Cervical Cancer

(f) BCSP - Breast and Cervical Screening Program

(g) CCRC - Continuing Care Retirement Community

(h) CHIP - Children's Health Insurance Program

(i) CHOICES - TennCare CHOICES in Long-Term Care

(j) CMS - Centers for Medicare & Medicaid Services

(k) COLA - Social Security cost-of-living adjustment

(l) CSIMA - Community Spouse Income Maintenance Allowance

(m) CSRMA - Community Spouse Resource Maintenance Allowance

(n) DAC - Disabled Adult Child

(o) DCS - Department of Children's Services

(p) DIMA - Dependent Income Maintenance Allowance

(q) ECF CHOICES - Employment and Community First CHOICES

(r) FEMA - Federal Emergency Management Agency

(s) FF - Families First

(t) FFM - Federally Facilitated Marketplace

(u) FFP - Federal Financial Participation

(v) FPL - Federal Poverty Level

(w) FRR - Financially Responsible Relatives

(x) HCBS - Home and Community Based Services

(y) HHS - United States Department of Health and Human Services

(z) HPE - Hospital Presumptive Eligibility

(aa) ICF/IID - Intermediate Care Facility for Individuals with Intellectual Disabilities

(bb) IRA - Individual Retirement Account

(cc) LTCP - Qualified Long-Term Care Insurance Partnership Policy

(dd) LTSS - Long-Term Services and Supports

(ee) MAGI - Modified Adjusted Gross Income

(ff) MIC - Medicaid Income Cap

(gg) MNIS - Medically Needy Income Standard

(hh) MSP - Medicare Savings Program

(ii) OASDI - Old-Age, Survivors, and Disability Insurance (Social Security Benefits)

(jj) PACE - Program of All-Inclusive Care for the Elderly

(kk) PASS - Plan to Achieve Self Support

(ll) PNA - Personal Needs Allowance

(mm) QDWI - Qualified Disabled and Working Individual

(nn) QHP - Qualified Health Plan

(oo) QIT - Qualified Income Trust

(pp) QI1 - Qualifying Individual

(qq) QMB - Qualified Medicare Beneficiary

(rr) SLMB - Specified Low Income Medicare Beneficiary

(ss) SSA - Social Security Administration

(tt) SSI - Supplemental Security Income

(uu) TANF - Temporary Assistance for Needy Families

(vv) VISTA - Volunteers in Service to America

(ww) WIOA - Workforce Innovation and Opportunity Act

(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. Emergency rules filed November 20, 2020; effective through May 19, 2021.)

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, 71-5-117, and 71-5-164 and TennCare II Section 1115(a) Medicaid Demonstration Waiver Extension.

The following state regulations pages link to this page.