1240-03-02-.02 - COVERAGE OF THE CATEGORICALLY NEEDY

1240-03-02-.02. COVERAGE OF THE CATEGORICALLY NEEDY

The following groups of categorically needy individuals, if otherwise eligible, are covered:

(1) Recipients Of Cash Assistance (Money Payments).

(a) All individuals receiving foster care maintenance payments or adoption assistance payments under Title IV-E of the Social Security Act are deemed eligible for Medicaid.

(b) All individuals receiving a benefit under Title XVI, Supplemental Security Income Program.

(c) All individuals receiving a State Supplemental payment.

(2) Medicaid Only (Non-Money Payment).

(a) Effective July 1, 2007, Medicaid and Families First de-linked. Eligibility for Families First will no longer mean automatic entitlement to Medicaid coverage. Families First applicants and recipients who also desire Medicaid must apply and have eligibility determined separate and apart from Families First.

1. Medicaid eligibility for Families First applicants and recipients, as well as Medicaid eligibility for those who are not applying for Families First will be considered in the AFDC-MO category. AFDC-MO provides Medicaid under Section 1931 of Title XIX of the Social Security Act [42 U.S.C. § 1396u-1] to individuals who meet the AFDC eligibility requirements in effect prior to July 16, 1996 in accordance with certain modifications approved by the Centers for Medicare and Medicaid Services (CMS) to Tennessee's State Plan as outlined in the Attachment 2.6-A, Supplement 12, page 1 and 2 of the State Plan.

(i) An AFDC-MO case terminated for earnings or increased earnings will continue eligible for Medicaid Only for an additional twelve (12) calendar months beginning with the month in which the family becomes ineligible for assistance except for the caretaker who is sanctioned for failure to comply with child support services. [42 U.S.C. § 608(a)(11), 42 U.S.C. § 1315, 42 U.S.C. § 1396u-1, 42 U.S.C. § 1396r-6 and 42 U.S.C. § 1396a(e)(1)]

(ii) Effective July 1, 2007 an AFDC-MO case terminated for receipt of spousal or child support will continue eligible for Medicaid Only for an additional twelve (12) months beginning with the month the family becomes ineligible for assistance.

(b) Any person or family who would be eligible for Families First/AFDC or SSI except for a requirement which is specially prohibited under Title XIX of the Social Security Act.

(c) Any Social Security beneficiary who would be currently eligible for Families First/AFDC or SSI if the Social Security increase in September, 1972, was disregarded, provided:

1. He received Old Age Assistance (OAA), Assistance for the Blind (AB), Assistance for the Disabled (AD), or Aid For Dependent Children (AFDC) in August 1972; and

2. Was also entitled to Social Security monthly benefits for August 1972.

(d) All aged, blind or disabled individuals in skilled or intermediate care as patients in the month of December 1973, who:

1. Would have received an OAA, AB, or AD money payment had they not been in skilled or intermediate care; and

2. Were certified for Medicaid Only on the basis of need for skilled or intermediate care; and

3. Continue to be eligible for Medicaid coverage because they:

(i) Continue to be patients in skilled or intermediate care facilities;

(ii) Continue to require skilled or intermediate care; and

(iii) Continue to meet all requirements as an OAA, AB, or AD Medicaid Only care according to policy in effect in December 1973, as contained in Volume II of the Public Welfare Manual.

(e) Any aged, blind, or disabled (AABD) individual who loses eligibility for Supplemental Security Income (SSI) benefits due to a Social Security (Title II) cost of living increase beginning in July 1977, but who would be eligible for SSI if cost of living adjustments received since their SSI termination were disregarded.

(f) Any aged, blind or disabled (AABD) individual institutionalized in a medical institution (i.e., one organized to provide medical care) or in Home and Community Based Services (HCBS) offered either through the CHOICES Program or through a Section 1915(c) of the Social Security Act [42 U.S.C. § 1396n(c)] HCBS waiver program who has income equal to or less than three hundred percent (300%) of the SSI Federal Benefit Rate and who meet all applicable technical and financial eligibility criteria.

1. TennCare CHOICES Program has two (2) components:

(i) Nursing Facility Services.

(ii) Home and Community Based Services (HCBS) for adults who are elderly or physically disabled.

2. There are two groups in TennCare CHOICES.

(i) CHOICES Group 1. Participation in CHOICES Group 1 is limited to Medicaid enrollees of all ages who qualify for and are receiving Medicaid-reimbursed Nursing Facility services. Medicaid eligibility for long-term care services is determined by the Department of Human Services (DHS). Medical (or level of care) eligibility is determined by TennCare as specified in Rule 1200-13-01-.10. Persons in CHOICES Group 1 must be enrolled in TennCare Medicaid and qualify for Medicaid-reimbursement of long-term care services.

(ii) CHOICES Group 2. Individuals age sixty-five (65) and older and adults age twenty-one (21) and older with physical disabilities who meet the Nursing Facility level of care and who qualify for TennCare either as SSI recipients or in the CHOICES 217-Like group and who need and are receiving HCBS as an alternative to NF care. Eligibility for the CHOICES 217-Like Group will be determined using the technical and financial criteria of the institutional eligibility category. TennCare has the discretion to apply an enrollment target to this group.

(I) SSI eligibles, who are determined eligible for SSI by the Social Security Administration. SSI eligibles are enrolled in TennCare Medicaid.

(II) The CHOICES 217-Like Group, as defined in Rule 1200-13-01-.02. Financial and categorical eligibility are determined by the Department of Human Services. Persons who qualify in the CHOICES 217-Like Group in accordance with Rule 1200-13-14-.02 are enrolled in TennCare Standard.

(g) Individuals who would be eligible for cash assistance (Families First/AFDC or SSI) except for their institutional status.

(h) Pregnant women who meet the income and resource standards of the Families First/AFDC cash assistance program. If eligible for and receiving Medicaid on the date of delivery, eligibility automatically continues for two full calendar months, beginning with the month following the month of delivery.

(i) A newborn infant may remain eligible for medicaid for a period of up to one year on the following conditions:

1. The mother was eligible for medicaid at the time the infant was born;

2. The mother would be eligible for medicaid if she were still pregnant; and

3. The child remains in the same household as the mother.

(j) Caretakers and their deprived children to age 21 when income from a sibling(s) (including half or step sibling) causes ineligibility for money payment.

(k) Pregnant women and infants up to one (1) year old who meet the income standards based on one hundred eighty-five percent (185%) of the federal poverty guidelines for the family size. If an application is made no later than delivery date and the pregnant woman is eligible at any time during the application processing period, eligibility continues without regard to income changes throughout the pregnancy. Eligibility continues for the pregnant woman two (2) full calendar months after the month pregnancy ends regardless of changes in the pregnant woman's eligibility status. A woman eligible under this subparagraph will receive full coverage in addition to pregnancy-related services. For purposes of this subparagraph, "pregnancy-related services" may mean any service eligible for coverage under the Medicaid program that potentially affects the pregnancy.

(l) Children age six or older who were born on or after October 1, 1983, whose family income does not exceed 100% of the Federal poverty guidelines and who meet all eligibility requirements.

(m) Any aged, blind, or disabled individual who loses eligibility for Supplemental Security Income (SSI) benefits due to any increase in income other than a Social Security (Title II) cost-of-living increase beginning in July 1977, but who would be eligible for SSI if cost of living adjustments received since their SSI termination were disregarded. (Commonly known as the Pickle Amendment.)

(n) Effective January 1, 1998, individuals who meet eligibility requirements for Specified Low-Income Beneficiaries (SLIB) except that income is greater than one hundred twenty percent (120%) of federal poverty guidelines, but not greater than one hundred thirty-five percent (135%) may be eligible for state buy-in of Part B Medicare premiums, if not currently eligible for or receiving Medicaid or TennCare on "first come, first served" basis up to the State's allocation of federal funds. This group is referred to as Qualifying Individuals 1 (QI1).

(o) Individuals under age 21 (or to age 22 if completing a course of treatment begun prior to the 21st birthday) receiving inpatient psychiatric care in a facility accredited by the Joint Commission for Accreditation of Hospitals.

(p) Legal aliens; immigrants who are not age sixty-five (65) or older, blind, disabled, or under age eighteen (18); undocumented aliens; and other aliens who do not have permanent resident status, including illegal aliens as specified under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) and the Deficit Reduction Act of 2005 (DRA), if otherwise eligible, may qualify for emergency medical services where the individual has a medical condition, including emergency labor and delivery, manifested by acute symptoms of sufficient severity which, if not attended to immediately, could reasonably be expected to result in placing the patient's health in serious jeopardy, severe impairment to bodily functions, or serious dysfunction of any bodily organ or part.

(q) Pregnant women who meet the applicable income levels for the categorically needy (i.e., those whose total income does not exceed one hundred eighty-five percent (185%) of the Federal poverty guidelines and who are determined eligible by a qualified provider for a presumptive eligibility period in accordance with Section 1920 of the Social Security Act) are eligible for ambulatory prenatal services. Only one (1) presumptive period of eligibility is allowed for each pregnancy.

(r) Qualified Medicare Beneficiaries who are entitled to Medicare Part A may be eligible for a State buy-in of their Medicare premiums, coinsurance and deductibles, if their resources do not exceed two hundred percent (200%) of the SSI resource limit for an individual or couple, as provided at 42 USC § 1382b and whose incomes do not exceed one hundred percent (100%) of the current federal poverty guidelines. Effective beginning with January 1, 2010, the resource limit is $6, 600 for an individual and $9, 910 for a couple.

(s) Qualified Disabled and Working Individuals who have not attained the age of 65, who would not otherwise be eligible for Medicare, who continue to meet the Social Security Administration's definition of disability or blindness (Title II), and whose entitlement to disability benefits ended solely because such individual's earnings exceeded the substantial gainful activity amount are eligible for a state buy-in of their Medicare Part A premiums, effective July 1, 1990 forward, provided such individual's income does not exceed 200% of the federal poverty guidelines applicable to a family of the size involved, provided such individual's resources do not exceed twice the maximum amount of resources that an individual or a couple may have under the SSI program and provided that the individual is not otherwise eligible for Medicaid.

(t) Children born on or after October 1, 1983, who have obtained the age of one year old but who have not obtained the age of six years old where family income does not exceed 133% of the Federal poverty guidelines and who meet all eligibility requirements.

(u) Specified Low-Income Medicare Beneficiaries (SLMB) who meet all of the requirements for Qualified Medicare Beneficiaries (QMB) but whose incomes are greater than one hundred percent (100%) but not greater than one hundred twenty percent (120%) of the current federal poverty guidelines may be eligible for state payment of their Part B (medical insurance) Medicare premiums if not Medicaid eligible.

(v) Disabled Widows and Widowers.

1. Any disabled widows or widowers who are between the ages of 50 and 59 and were entitled to Title II widow and widowers Social Security Benefits during December 1983 and lost their Supplemental Security Income (SSI) benefits under Title XVI as a result of elimination of the actuarial reduction factor in January 1984 but who would have continued SSI eligibility if the Social Security increase, which arose from the elimination of the actuarial reduction factor and all subsequent Cost of Living Adjustments (COLA), is disregarded provided that application for this benefit was made no later than July 1, 1987.

2. Any disabled widow or widower who lost eligibility for SSI benefits because of receiving at age 60 a spouse's retirement benefit under Title II may remain eligible for Medicaid on the following conditions:

(i) They are not entitled to Medicare Part A coverage; and

(ii) They would be eligible for SSI if cost of living adjustments and the spouse's retirement benefits were disregarded.

3. Any disabled widow(er) or disabled divorced surviving spouse who lost SSI eligibility due to a receipt of Title II benefits which were received pursuant to 1990 changes in disability criteria of 42 USC § 423 may remain eligible for Medicaid on the following conditions:

(i) They are not entitled to Medicare Part A coverage; and

(ii) They would continue to be eligible for SSI if the Title II benefit was not counted as income.

(w) Disabled adult children who lose SSI eligibility after July 1, 1987 because of the receipt of or an increase in benefits for Disabled Adult Children under Title II will remain eligible for Medicaid if the initial entitlement under Title II above and/or cost of living increase, whichever caused the ineligibility for SSI, were disregarded.

(x) Women who have been found to have breast or cervical cancer including a precancerous condition, through the National Breast and Cervical Cancer Early Detection Program, who are under age sixty-five (65) and are uninsured and not otherwise eligible for Medicaid or receiving TennCare Standard are eligible to receive Medicaid in the Breast and Cervical Cancer category.

(3) Children Under 21 In Special Living Arrangements.

(a) Children in foster care or a subsidized adoptive home;

(b) Children under the supervision of the Department, or approved public child care agency (if the Department is providing some portion of the child's cost of care), or a licensed private, non-profit child-care or child planning agency; and

(c) Who are in need according to the Families First/AFDC-FC Income and Resource Standards.

(Original rule filed June 14, 1976. Amendment filed September 15, 1977; effective October 14, 1977. Amendment filed June 9, 1981; effective October 5, 1981. Amendment filed November 30, 1981; effective January 14, 1982. Repeal and new rule filed August 17, 1982; effective September 16, 1982. Amendment filed October 14, 1983; effective November 14, 1983. Amendment filed January 7, 1985; effective February 6, 1985. Amendment filed May 23, 1986; effective August 12, 1986. Amendment filed August 9, 1989; effective September 13, 1989. Amendment filed January 31, 1990; effective March 17, 1990. Amendment filed May 1, 1991; effective June 15, 1991. 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 June 1, 2007; expires November 13, 2007. Public necessity rule filed July 2, 2007; effective through December 14, 2007. Amendment filed August 30, 2007; effective November 13, 2007. Amendments filed September 25, 2007; effective December 9, 2007. Amendment filed April 22, 2008; effective July 6, 2008. Amendments filed August 5, 2009; effective November 3, 2009. Emergency rule filed March 1, 2010; effective through August 28, 2010. Amendments filed May 25, 2010; effective August 23, 2010.)

Authority T.C.A. §§ 4-5-201 et seq., 4-5-202, 4-5-208, 71-1-105(12), 71-3-158(d)(2)(D), 71-5-101, 71-5-102, 71-5-103, 71-5-106, 71-5-109, 71-5-111 and 71-5-1401 et seq.; Acts 2007, Chapter 31 § 11 and Acts 2008, Chapter 1190; 8 U.S.C. §§ 1611, 1612, 1613 and 1641, 42 U.S.C. § 423 note, 42 U.S.C. § 608(a)(2), 42 U.S.C. § 608(a)(6), 42 U.S.C. § 608(a)(11), 42 U.S.C. § 672(h), 42 U.S.C. § 673(b), 42 U.S.C. § 1315, 42 U.S.C. §§ 1382 et seq., 42 U.S.C. § 1382b, 42 U.S.C. § 1395w-114(a)(3)(D), 42 U.S.C. §§ 1396 et seq., 42 U.S.C. § 1396a(a)(10)(A)(i), 42 U.S.C. § 1396a(a)10(A)(i)(1V), 42 U.S.C. § 1396a(a)(10)(E); 42 U.S.C. § 1396d(p)(1)(c), 42 U.S.C. § 1396a(e)(1)(A), 42 U.S.C. § 1396a(e)(4)(5) and (6), 42 U.S.C. 1396 a(l)(1)(D), 42 U.S.C. § 1396a(aa), 42 U.S.C. 1396 b(v)(1), 42 U.S.C. § 1396d(p)(1), (2) and (3), 42 U.S.C. § 1396d(s), 42 U.S.C. § 1396n(c), 42 U.S.C. § 1396r, 42 U.S.C. § 1396r-6, 42 U.S.C. § 1396u-1; 20 C.F.R. 416.1205(c); 42 C.F.R. §§ 435.4, 435.100, 42 C.F.R. 435.200, and 42 C.F.R. 435.831; PL 94-566 § 503; PL 98-21 § 134; PL 99-509 § 9401; PL 100-203 § 9116; PL 101-508 § 5103(e), PL 104-193 §§ 103 and 431 and PL 109-171 § 6036 and 7101; 71 PL 110-275, Title I, § 112, FR 39214 (July 6, 2006), and Acts 2008, Chapter 1190.

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