TennCare
Darin Gordon, Deputy Commissioner

AFDC MO (1931)

Brief Description
Individuals who meet basic Family’s First criteria for Title XIX, but do not qualify for certain technical components of Family’s First.

Monthly Income Limit
(1) $1288
(2) $1658
(3) $1972
(4) $2240

Resource Limit
$2000

Comments
This is a mandatory program for states, although states can set the income standards. Eligibility is determined by DHS. Monthly cash assistance is not provided by DHS.

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AFDC Pregnant Women

Brief Description
Pregnant Women who do not qualify in any other Medicaid category but would qualify for TANF/AFDC if other children were in the home.

Monthly Income Limit
(1) $1217 
(2) $1574
(3) $1837
(4) $2011

Resource Limit
$2000

Comments
This is a mandatory program for states, although states can set the income standards. Eligibility is determined by DHS. Monthly cash assistance is not provided by DHS.

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Newborns

Brief Description
Children born to Medicaid eligible women.

Monthly Income Limit
None

Resource Limit
None

Comments
Newborns are  automatically eligible for one (1) year after birth and then eligibility must be redetermined by DHS.

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Medically Needy

Brief Description
Low income persons who are also one of the following:

• Some children up to age 21
• A pregnant woman or child under age 18

Monthly Income Limit
Individual must either have income no more than the figures provided below OR he must have sufficient unreimbursed medical bills to "spend down" to these income limits, depending upon family size:

$241 (1)

$258 (2)

$317 (3)

$325 (4)

Resource Limit
$2000 (1)

$3000 (2)

Comments
This is an optional Medicaid category. Eligibility is determined by DHS.
The "spend down" income level is set by the state.

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PLIS (Poverty Level Income Standard,
Pregnant women and children)

Brief Description
Low income pregnant women and children up to age 19.

Monthly Income Limit

• Pregnant women and infants to age 1: 185% poverty
  ($2713 for a family of 3)

• Children from age 1 to age 6: 133% poverty
  ($1951 for a family of 3)

• Children from age 6 to age 19: 100% poverty
  ($1467 for a family of 3)

Resource Limit
None

Comments
This is a mandatory Medicaid eligibility category, although coverage of pregnant women and infants between 133% and 185% of poverty is optional for states. Eligibility is determined by DHS.

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Supplemental Security Income (SSI)

Brief Description
Low income aged, blind, and/or disabled individuals.

Monthly Income Limit
$674 (1)
$1,011 (2)

Resource Limit
$2000 (1)
$3000 (2)

Comments
This is a mandatory Medicaid eligibility category. Eligibility is determined by the Social Security Administration. Monthly cash assistance is provided by SSA.

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Institutionalized Individuals

Brief Description
Low income persons who require care in a nursing facility (NF) or intermediate care facility for the mentally retarded (ICF/MR) or who receive Home and Community-based Services (HCBS).

Monthly Income Limit
$2,022 (300% of the SSI benefit rate)

Resource Limit
$2000

Comments
This is an optional Medicaid eligibility category. Need for placement in a NF, ICF/MR or HCBS is determined by the Bureau of TennCare or the Division of Mental Retardation Services. Financial eligibility is determined by DHS.

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Women with Breast or Cervical Cancer

Brief Description
The Breast and Cervical Cancer Prevention (BCCP) category is an optional Medicaid category that covers women who have been screened through a Centers for Disease Control and Prevention (“CDC”) approved Breast and Cervical Cancer Early Detection Program (“BCCP”) and found to need treatment for breast and/or cervical cancer. In Tennessee the state program is operated by the Tennessee Department of Health (DOH), through the county health departments, and called the "TN Breast and Cervical Screening Program."

Tennessee women who are uninsured or whose insurance does not cover treatment for breast or cervical cancer, who are under age 65, and who have been determined by the County Health Department to need treatment for breast or cervical cancer are eligible to enrollee in TennCare Medicaid.

Monthly Income Limit
The screening guidelines required by the CDC Breast and Cervical Cancer Early Detection Program requires screened eligibles be below 250 percent of the federal poverty level.

Resource Limit
None

Comments

HOW TO APPLY - Presumptive eligibilityis an established period of time (45 days) during which certain women identified by the DOH as being uninsured and needing treatment for breast or cervical cancer—are eligible for Medicaid. During this period of time the presumptively eligible person must complete an application for Medicaid in order to stay on the program. All applicants must complete a written application for Medicaid and be interviewed by a worker with the county office of the Department of Human Services (DHS).

Presumptive eligibility lasts for a period of 45 days. During the presumptive eligibility period, the enrollee must go to the DHS office to complete her enrollment in Medicaid. The DHS worker first evaluates the woman to determine if she is eligible for any other Medicaid category. If she is not eligible in another Medicaid category, the worker evaluates her for the optional Medicaid category to cover her during the time she needs treatment for cervical or breast cancer. A redetermination of eligibility will occur at least every 12 months at the DHS office and will be based on the need for continuing treatment for breast or cervical cancer, as determined by the woman’s treating physician.

The effective date of eligibility is the date an application is approved at the Department of Health or at any alternative sites chosen by the Department of Health.

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TennCare Standard

Uninsured*

Brief Description

This category is only available to children under age 19 whose TennCare Medicaid eligibility is ending, who do not have access to insurance through a job or a family member’s job, and whose family incomes are below 200% poverty.

Monthly Income Limit
100% Poverty
$867 (1)
$1167 (2)
$1467 (3)

200% poverty
$1733 (1)
$2333 (2)
$2933 (3)

Resource Limit
None

Comments
"Uninsured" means without access to insurance through one’s job or a family member’s job. 

Medically Eligible*

Brief Description
This category is only available to children under age 19 whose TennCare Medicaid eligibility is ending and whose family income equals or is greater than 200% of poverty. To be medically eligible, the child must have health conditions that make the child "uninsurable." The family is unable to purchase healthcare insurance for the child in the private market because of the child's health conditions.

Monthly Income Limit
Coinsurance for some services is required for a TennCare Standard Uninsured child or TennCare Standard Medically Eligible child if the family income is over 99% poverty:
$867 (1)
$1167 (2)
$1467 (3)
$1767 (4)

Resource Limit
None

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Qualifying Individuals (QI 1)

Brief Description
Cost sharing assistance for low income Medicare beneficiaries. You must meet criteria for one of the other Medicaid categories in order to get TennCare Medicaid.

Monthly Income Limit
Between 120% and 135% poverty
$1170 (1)
$1575 (2)

Resource Limit
$4000 (1)
$6000 (2)

Comments
This is a mandatory Medicaid eligibility category. State is required to pay Medicare Part B premiums for these individuals as long as federal funds are available. They are not eligible for TennCare unless they meet the criteria for one of the other eligibility categories. Eligibility determined by DHS.

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Qualified Disabled Working Individuals (QDWI)

Brief Description
Low income disabled working individuals under age 65 who are entitled to Medicare Part A. You must meet criteria for one of the other Medicaid categories in order to get TennCare Medicaid.

Monthly Income Limit
200% poverty
$1733 (1)
$2333 (2)
$2933 (3)

Resource Limit
$4000 (1)
$6000 (2)

Comments
This is a mandatory Medicaid eligibility category. State is required to pay Medicare Part A premiums for these individuals. They are not eligible for TennCare unless they meet the criteria for one of the other eligibility categories. Eligibility for QDWI status is determined by DHS.

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Qualified Medicare Beneficiaries (QMB)

Brief Description
Low income persons eligible for Medicare Part A. You must meet criteria for one of the other Medicaid categories in order to get TennCare Medicaid.

Monthly Income Limit
100% poverty
$867 (1)
$1167 (2)

Resource Limit
$4000 (1)
$6000 (2)

Comments
This is a mandatory Medicaid eligibility category. State is required to pay Medicare premiums, deductibles, and coinsurance for these individuals. They are not eligible for TennCare unless they meet the criteria for one of the other eligibility categories. Eligibility for QMB status is determined by DHS.

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Special Low Income Medicare Beneficiaries (SLMB)

Brief Description
Low income Medicare beneficiaries. You must meet criteria for one of the other Medicaid categories in order to get TennCare Medicaid.

Monthly Income Limit
120% poverty
$1040 (1)
$1400 (2)

Resource Limit
$4000 (1)
$6000 (2)

Comments
This is a mandatory Medicaid eligibility category. State is required to pay Medicare Part B premiums for these individuals. They are not eligible for TennCare unless they meet the criteria for one of the other eligibility categories.

Eligibility for SLMB status is determined by DHS.

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