1. TennCare Redetermination
Christopher Coleman
Staff Attorney
Wednesday, April 26, 2017
Tennessee Justice Center

2. “A Rose is a Rose is a Rose” – Gertrude Stein
“Redeterminations” = “Renewals” = “Reverifications”= “Recertifications”
10/27/2016

3. Periodic Redetermination of Medicaid Eligibility
By federal law, all Medicaid (TennCare) enrollees must have their eligibility redetermined every 12 months. 42 CFR (a) and (b)
For MAGI, no more frequently than once every 12 months.
§  Periodic renewal of Medicaid eligibility.(a) Renewal of individuals whose Medicaid eligibility is based on modified adjusted gross income methods (MAGI). (1) Except as provided in paragraph (d) of this section, the eligibility of Medicaid beneficiaries whose financial eligibility is determined using MAGI-based income must be renewed once every 12 months, and no more frequently than once every 12 months.
10/27/2016

4. The State is Required to…
Extend coverage for all enrollees whose current eligibility can be determined by review of records already available to the state. (“Ex parte review”)
Afford enrollees an opportunity to provide any missing information or documentation.
Provide assistance – in person & by phone.
Assess enrollees’ eligibility in all open categories of TennCare.
10/27/2016

5. The State is Required to…
If ineligible for TennCare, determine eligibility for other insurance affordability programs (CoverKids, PTCs, CSRs).
Electronically transfer files to the Marketplace for those determined eligible for other insurance affordability programs.
Notify enrollees of the state’s determination.
10/27/2016

6. The Enrollee is Required to…
Keep TennCare informed of any changes in contact information.
Report changes in income and/or household composition.
Fill out and return redetermination packets within 40 days.
Provide supporting documentation, as requested by the state.
10/27/2016

7. Reconsideration
(iii) Reconsider in a timely manner the eligibility of an individual who is terminated for failure to submit the renewal form or necessary information, if the individual subsequently submits the renewal form within 90 days after the date of termination, or a longer period elected by the State, without requiring a new application. 42 CFR (a)
10/27/2016

8. TennCare’s Redetermination Process
10/27/2016

9. Three Phases Phase 1: SNAP match (May & September 2015)
Phase 2: confirmation mailing (October-December 2015)
Phase 3: “renewal packet”(December 2015, January 2016, & present)
10/27/2016

10. Phase 3 December 2015: Pilot group of 10,000
February 2016: Redetermination halted
June 2016: Process resumed
Now:
Redetermination of 100,000+ people
10/27/2016

11. Challenges in Completing the “Renewal Packet”
10/27/2016

12. Seven Challenges: Extensive requests for information
Enrollees may not receive the redetermination packet
Individualized barcodes on packets
SSI-related eligibility categories
Eligible immigration statuses
Resources/assets
Enrollees may fail to take timely action
10/27/2016

13. Challenge 1: Extensive requests for information
10/27/2016

14. “Renewal Packet”
The state still lacks a functioning computer system for determining eligibility.
TennCare is mailing massive 98-page “Renewal Packets” to families to complete and return.
Not pre-populated with information already available to the state.
Example “Renewal Packet”:
10/27/2016

15. What’s in the 98-page packet?
English version – 47 pages
Notice (includes deadline for returning packet) – 3 pages
Renewal Packet – 13 pages
Appendix A (screening for some non-MAGI categories) – 4 pages
Appendix B (for American Indian or Alaska Native family members) – 1 page
Instruction packet – 26 pages
Spanish version – 48 pages
“Do You Need Special Help?” (English and Spanish) – 2 pages
Other languages – 1 page
10/27/2016

16. LTSS “Renewal Packet”
Long-Term Services and Supports (LTSS) redetermination packets are 119 pages.
The state said they resumed LTSS redeterminations in August.
Example LTSS “Renewal Packet”:
10/27/2016

17. Challenge 2: Enrollees May Not Receive the Redetermination Packet
10/27/2016

18. Enrollees May Not Receive the Redetermination Packet
Census Bureau’s research shows that at least one third of enrollees are likely to have moved since their eligibility was last determined.
Even if they reported a change in address, they can’t be sure the new address made its way into the system.
Talk about how those enrollees who lose coverage will wash up on the shore of providers.
10/27/2016

19. Change of Address Form TennCare Change of Address Reporting Form
English:
Spanish:
TJC recommends reporting changes by fax ( ) and saving fax receipt.
10/27/2016

20. Was I supposed to get a packet?
Call Tennessee Health Connection (TNHC) at and ask what address they have on file. Update address if needed.
Ask TNHC if you were supposed to get a redetermination packet.
If yes, request that TNHC sends you a new redetermination packet.
Record date, time, & the name of the TNHC representative whom you spoke to.
10/27/2016

21. Challenge 3: Individualized Barcodes
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22. Individualized Barcode
Barcode on bottom, left-hand side is unique to each “renewal packet” & on every page.
10/27/2016

23. Individualized Barcode
Circled area is not true. Barcode on each packet is individualized. Other people outside of the household cannot use someone else’s packet.
Circled language is potentially misleading: can only use packet for the people to whom the packet was addressed, whether or not their coverage is ended.
Renewal Packet, page 1 of 13
10/27/2016

24. Do NOT make copies of the redetermination packet for other people to use.
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25. What if multiple family members receive a redetermination packet?
Each family member who receives a redetermination packet must fill it out in its entirety.
If some family members get a packet and others do not, call Tennessee Health Connection (TNHC) at Verify address for all family members. Ask who was supposed to receive the packet.
If someone was supposed to receive a packet but didn’t, ask TNHC to send another one.
Record date, time, & the name of the TNHC representative whom you spoke to.
Note: Parents can sign for their minor children. They are automatically legal “authorized representatives” and don’t need to fill out part about being an authorized representative.
10/27/2016

26. Challenge 4: SSI-related Eligibility Categories (Pickle, DAC, DAW, 1619(b))
10/27/2016

27. SSI-related Eligibility Categories
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28. Challenge 5: Eligible Immigration Statuses
10/27/2016

29. Eligible Immigration Statuses
Renewal Packet, page 3 of 13
10/27/2016

30. Instruction Packet: Eligible Immigration Statuses
Instruction Packet, page 4 of 26
10/27/2016

31. Qualified Immigrants LPR: Lawful Permanent Residents (green card)
Refugees
Asylees
Aliens paroled in the U.S.
Aliens whose deportation is being withheld
Battered immigrants and children
Cuban/Haitian entrants
Aliens granted conditional entry
Victims of a severe form of trafficking
10/27/2016

32. Treated like “Qualified Aliens” for TennCare & CoverKids Eligibility
Amerasian Immigrants
Aliens who are members of a Federally-recognized Indian tribe
American Indians born in Canada
Aliens who are honorably discharged veterans or active duty members of the U.S. Armed Forces, plus their spouse and dependent children
Afghani and Iraqi aliens granted Special Immigrant Status
Aliens who are victims of a severe form of trafficking
10/27/2016

33. Time-Related Requirements
5-year bar: period of ineligibility for all federally-funded benefits, including full TennCare and CoverKids
Only applies to certain groups of qualified immigrants
10/27/2016

34. Included in the 5-Year Bar
Legal Permanent Residents (LPR) admitted on or after 8/22/96
I-551 with various codes
Aliens paroled for at least 1 year
I-94 with code 212(d)(5) or other language indicating parole status
Battered immigrants and children
Petition for:  
Immediate relative status;  
Classification to immigrant status based on relationship to a lawful permanent resident alien; or  
Suspension of deportation and adjustment to lawful permanent resident status. 
10/27/2016

35. Exempt from the 5-Year Bar
LPRs (admitted before 8/22/1996)
LPRs who first entered the country under another exempt category (i.e. as a refugee) and who later converted to LPR status
Victims of a severe form of trafficking
Refugees, asylees, and other humanitarian immigrants
Aliens who are discharged veterans
Aliens who are on active duty in the U.S. military
Aliens who are the spouse or unmarried dependent child of an veteran or active member of the U.S. military
Members of a Federally-recognized Indian tribe
American Indians born in Canada
Refer to TJC if not sure if someone has an eligible immigration status.
10/27/2016

36. Challenge 6: Resources/Assets
10/27/2016

37. Resources: Property No designation of homestead
Appendix A, Page 3 of 4
10/27/2016

38. Challenge 7: Enrollees May Fail to Take Timely Action
10/27/2016

39. Timeframes 40 days to fill out and return the redetermination packet.
Failure submit packet or document eligibility will result in termination of TennCare.
Save fax receipt, OR request certified mail receipt
10 days to respond to request for more information.
Note: Packet is printed front and back – do NOT fax over just the fronts of each page.
10/27/2016

40. Continuation of benefits during appeal
10 days from notice of termination to request an appeal with continuation of benefits. (Save fax receipt or certified mail receipt!)
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41. Continuation of benefits
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42. What if an enrollee doesn’t return the packet in 40 days?
The termination notice informs the individual they have 20 days to respond by submitting a completed redetermination packet.
But individual can return the completed redetermination packet within 90 days to be reinstated. If approved during those 90 days, coverage will be reinstated with no gap.
10/27/2016

43. How can an enrollee get help with the “Renewal Packet”?
10/27/2016

44. Resources/Assistance
The current redetermination process looks different than in the past.
Enrollees do not have a case worker they can contact.
10/27/2016

45. Resources/Assistance
Renewal Packet, page 11 of 13
10/27/2016

46. Resources/Assistance
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47. Resources/Assistance
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48. Gap-Filling Rule
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49. Gap-Filling Rule
(i) If the household income of an individual determined in accordance with this section results in financial ineligibility for Medicaid and the household income of such individual determined in accordance with 26 CFR 1.36B-1(e) is below 100 percent FPL, Medicaid financial eligibility will be determined in accordance with 26 CFR 1.36B-1(e).
42 CFR (i)
10/27/2016

50. Gap-Filling Rule
Why: Because eligibility for TennCare and premium tax credits use different methodologies, the same income can be computed differently for different insurance affordability programs. Household composition varies as well.
Purpose: To keep you from losing TennCare due to an income calculation that makes you ineligible for premium tax credits.
Effect: Seamless eligibility for insurance affordability programs.
10/27/2016

51. Gap-Filling Rule Flowchart
Categorically eligible under MAGI? No
Yes
Eligible monthly income?
Not eligible  No
Yes
Apply for TennCare!
Projected annual household income below 100% FPL? No
Yes
Eligible under gap-filling rule
Not eligible 
10/27/2016

52. Screening for the Gap-Filling Rule
1. Is the person currently categorically eligible in a MAGI category? 2. If yes, does their monthly income make them eligible for TennCare? 3. If no, is the person’s projected “household” yearly income below 100% FPL? 4. If yes, the person remains eligible for TennCare under the Gap-Filling rule.
10/27/2016

53. How to Apply the Gap-Filling Rule
Return the redetermination packet. Provide supplemental income documents and a letter explaining that the enrollee is eligible under the Gap-Filling Rule. Save proof of sending.
If the person’s TennCare is terminated, file an appeal and ask for continuation of benefits (COB). Say they are eligible under the Gap-Filling Rule. (
Call TJC! ( or )
10/27/2016

54. Recap: Gap-Filling Rule
If the individual… 1. Meets the categorical requirement for MAGI (e.g. parent/caretaker relative, children), AND 2. Has annualized income below 100% FPL THEN they maintain TennCare eligibility, even though their monthly income is too high.
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55. Main Takeaways
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56. Main Takeaways
Contact Tennessee Health Connection to make sure they have the correct address on file, and report any changes.
If you have not received a packet, ask Tennessee Health Connection if you were due to receive one.
Make copies of all documents you send to TennCare, and ask the post office for proof of mailing.
10/27/2016

57. Main Takeaways
Failure to return the packet or respond to request for additional information will lead to loss of coverage.
Packets are complex and difficult to complete.
The packets fail to capture information needed to ensure that people who are eligible retain their coverage.
There is much greater need for help in this process than in applying for coverage on the Marketplace.
10/27/2016

58. Main Takeaways Document everything!
Complete and return all forms by the deadlines. If you cannot meet a deadline, send what you have and ask for more time to send the rest.
If terminated, appeal with continuation of benefits within 10 days of the termination notice.
If an enrollee has a disability, call Tennessee Health Connection and tell them. Ask them for help completing the forms. Keep a record of the call.
10/27/2016

59. Refer Cases to TJC
If a client is having trouble navigating the redetermination process, you can refer the case to TJC: Andy Hofer, TJC’s Intake Coordinator at
10/27/2016

60. Questions?
10/27/2016

61. Thank you for joining us!
“Of all the forms of inequality,
injustice in health care is the most shocking and inhumane.”
-Martin Luther King, Jr.