navigating tenncare & the marketplace · navigating tenncare & the marketplace tennessee...

10/8/2014

1

Navigating TennCare

& the Marketplace

Tennessee Justice Center

301 Charlotte Ave | Nashville, TN, 37201

615-255-0331

Day 1: The Rules to Live By

10/8/2014

Agenda

Day 1

• Pre-Test

• Counting Income

• Counting Household

Size

• TennCare Categories

• Filling the Knowledge

Gap

Day 2

• Marketplace Basics

• Wilson v. Gordon

• Scenarios

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Pre-Test Time!

• Please take out the “Pre-Test” in your folder.

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2

MAGI

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Why Household Income Matters

Necessary to convert income to a federal

poverty level (FPL) standard.

Household size 100% 138% 200% 250% 400%

1 $11,670 $16,105 $23,340 $29,175 $46,680

2 $15,730 $21,707 $31,460 $39,325 $62,920

3 $19,790 $27,310 $39,580 $49,475 $79,160

4 $23,850 $32,913 $47,700 $59,625 $95,400

5 $27,910 $38,516 $55,820 $69,775 $111,640

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What is MAGI?• MAGI is a methodology for how income is counted for:

• Medicaid eligibility

• CHIP/CoverKids

• Premium Tax Credits

• Cost-Sharing Subsidies

• MAGI is based on federal tax rules for determining adjusted gross income (with some modification)

• No asset test or disregards • except a 5% disregard for those who would otherwise be

ineligible – does not apply to PTC/CSR

• See TJC Coverage Cheat Sheet – page 7

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3

Whose eligibility is based on MAGI?

MAGI Non-MAGI

Parents and Caretaker Relatives Anyone for whom agency not

required to make income

determination (e.g.,

SSI, federal foster care or adoption

assistance recipients)

Pregnant Women CHOICES

Children Medically Needy Spend-Down

New “adult group” (if Tennessee expands

Medicaid)

Medicare Savings Programs (MSP)

Breast and Cervical Cancer

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Household Income using MAGI• Household income = sum of MAGI of every

individual in the household

• Except:

– Income of tax dependents not required to file taxes.

• Threshold: 6,100/yr in earned or $1,000/yr in unearned with some key exceptions;

• See IRS Publication 929 Tax Rules for Children & Dependents

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Income of Tax Dependents

Maddie & Daphne

make $3,050 a

piece for playing

at an awards

show.

Is this income part

of the household’s

MAGI?

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4

Income of Tax Dependents

Several Exceptions:

• Some Church wages

• Self-Employmentnet earnings of $400 or more.

• Uncollected Social Security Medicare taxes on tipsANSWER: Need More Info!

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Gross Income – 1040 (Lines 7-22)

See IRS Publication 17 Your Federal Income Tax10/8/2014

Step 1: Gross Income

Earned Income

• Wages, salaries, tips (W-2 form)

• Self-employment, business and farm

income after deduction of business

expenses (including depreciation and

capital losses – Schedule C); or

independent contractor (1099 form)

TJC Toolkit page 610/8/2014

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5

Gross IncomeUnearned Income• Investments

– Dividends & Interest

– Capital/other gains

• Social Security (SSA) income (taxable amount)

• Retirement– IRA distributions (taxable amount only), pensions, annuities

• Taxable state income tax refunds and credits

• Alimony received

• Rental real estate income, Farm Income and royalties

• Unemployment Compensation

• Other income if taxable (prizes, jury duty pay, etc.)

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Adjusted Gross Income – 1040 (Lines 23-37)

See IRS Publication 17 Your Federal Income Tax10/8/2014

Step 2: Adjusted Gross Income (AGI)

Gross Income LESS Deductions (Lines: 23 – 37)

• Certain Business/Self-employment expenses

• Estate and trust loss

• Educator expenses (limit of $250 per educator in a tax year)

• Real estate mortgage investment loss

• Business expenses of Reservists, Performing Artists, and Fee-

Basis Government Officials

• Health Savings Account

• Moving Expenses (if moved in connection with new job)


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6

And these deductions (AGI continued) • Tax deductible part of self-employment tax

• Self-employed SEP, SIMPLE and qualified plans

• Self-employed health insurance deduction

• Penalty on early withdrawal of savings

• Alimony paid

• IRA deduction

• Student loan interest (limit of $2,500 in a tax year)

• Tuition and fees (limit of $4,000 in a tax year)

• Domestic production activities deduction (up to 9% of qualified activities)


Step 3: from AGI to MAGI

Modified Adjusted Gross Income (MAGI) is calculated by adding back certain items to your Adjusted Gross Income including:

• Foreign Income

• Tax Exempt Interest

• Non-taxable Social Security benefits

– NOTE: this means ALL Social Security benefits (disability and retirement, NOT SSI) are included at some point in the MAGI calculation • Taxable in Gross Income + Non-Taxable in Modified AGI


What About Items Like:

Life Insurance Proceeds – lump sum proceeds

paid to a beneficiary are usually not considered

income.

Gifts and Inheritances of Money or Property – is

not considered income to the recipient. In

general, gift amount limit is $14,000 (for 2014)

without triggering a gift tax return (Grantor files).

For MAGI

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7

Calculating MAGI: Lamar• Rayna’s dad, Lamar, is 62.

• In 2012, he had a stroke and began getting SSDI.

• Gets SSDI for $900/mo.

• Has $1200 in savings.

• Receives $600/mo in royalitiesfrom deceased wife’s records.

• Lamar pays $150/mo in child support for a yet-to-be disclosed child

• Received a one-time gift of $11,000 from Rayna

10/8/2014

Calculating MAGI: Lamar• Rayna’s dad, Lamar, is 62.

• In 2012, he had a stroke and began getting SSDI.

• Gets SSDI for $900/mo.

• Has $1200 in savings.

• Receives $600/mo in royalitiesfrom deceased wife’s records.

• Lamar pays $150/mo in child support for a yet-to-be disclosed child

• Received a one-time gift of $11,000 from Rayna

Lamar’s MAGI = $1,500

X 12 =

$18,000/yr10/8/2014

Quick MAGI Income ReviewIncome Source MAGI Medicaid Rules

Self-employment income Counted with deductions for most

expenses, depreciation, and business

losses

Salary deferrals (flexible spending, 401(k)

plans)

Not counted

Child support received Not counted

Alimony paid Deducted from income

Veterans’ benefits Not counted

Workers’ compensation Not counted

Gifts & inheritances Not counted

TANF (FF) & SSI Not counted

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8

TennCare Eligibility Standards Using MAGI

ChildrenPregnant

WomenTennCare

Ages 0-1

TennCare

Ages 1-5

TennCare

Ages 6-18

Cover

Kids

MAGI Standard 200% 147% 138% 255% 200%

Parent & Caretaker Relatives

Household Size 1 2 3 4

MAGI Standard $1,066 $1,394 $1,693 $1,966

(See TJC Coverage Cheat Sheet)

TJC Toolkit Page 7

10/8/2014

Practice Tips:Parents & Caretaker Relatives: when working with a family make sure to check for coverage;

Check Dependents – only count their income if required to file taxes. Check Exceptions.

MAGI – No resource tests. Instead, MAGI has 5% across-the-board disregard.

Tax Credits vs. TennCare – Estimated Yearly vs. Month of application income.

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Household

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Household Size Under MAGI

• Individual-based determination

–Members of the same household could have

different household sizes

• Three categories of individuals

– Tax filers not claimed as a tax dependent

– Tax Dependents

– Non-filers and not claimed as a tax dependent

• Based on expected tax filing status

10/8/2014

There are only two possibilities

1. Household size = tax filing unit (always

applies to Premium Tax Credits and to Tax

Filers for Medicaid)

2. Household size = Parents, children, and

siblings living together (always applies to

non-filers not claimed as a dependent; only

applies to Medicaid)

10/8/2014

Household Size for

Premium Tax Credits

Household size = Tax filing unit

• Tax filer (includes married taxpayers filing jointly) and all claimed tax dependents.

• Includes family members and unrelated individuals claimed as a tax dependent by a taxpayer (e.g., stepchild, grandchild, niece, taxpayer’s parent).

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Household Size for

Premium Tax Credits

Household size = 3

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Household Size for Medicaid:

Tax Filer Not Claimed as a Dependent

Household size = Tax filing unit

For tax filers, rules for household size are always

the same, regardless of the program.

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Medicaid Rule for Non-filers, Not

Claimed as a Dependent

• Adults: Household = individual plus spouse

and children (including step-children)

• Children: Household = child plus siblings and

parents (including step-parents) living with

child.

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Medicaid Rule for Tax Dependents• Household = household of the tax filer

claiming the dependent (tax filing unit),

unless . . .

– Tax dependent is not the child or spouse of the tax filer

– Tax dependent is a child living with both parents who are unmarried

– Tax dependent is a child claimed as a tax dependent by a non-custodial parent

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Deacon• Deacon lives alone, of course.

• Deacon is not claimed as a dependent on anyone else’s tax return and has no tax dependents.

Counted in HH HH Size for

MedicaidDeacon

Deacon ✔ 1

Medicaid Household Size10/8/2014

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12

Conrad-James Family (pre-divorce)

• Conrad-James family: married couple with 2 children

• Teddy and Rayna file a joint return and claim both children as dependents

Counted in HH HH Size

for

MedicaidRayna Teddy Maddie Daphne

Rayna

Teddy

Maddie

Daphne ✔

✔

✔

✔

✔ ✔

✔

✔ ✔

✔

✔ ✔

✔ ✔ ✔✔ 4

4

4

4


Conrad≠James Family (aHer divorce)• Rayna lives with both

daughters and files taxes as a single individual

• Teddy claims girls as tax dependents

Lisa

Son

Father


MedicaidRayna Maddie Daphne Teddy

Rayna

Maddie

Daphne

Teddy

✔

✔✔

✔✔

1

3

3

✔

✔

✔ ✔ ✔

3


Conrad≠James Family (after divorce)• Rayna lives with both

daughters. Rayna claims Maddie as a tax dependent.

• Teddy claims Daphne as a tax dependent.

Lisa

Son

Father


MedicaidRayna Maddie Daphne Teddy

Rayna

Maddie

Daphne

Teddy

✔

✔

✔✔

2

2

3

✔

✔ ✔ ✔

2

✔


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Juliette – Three-Generation Household

• Juliette lives with and supports her 44-year old mother, Jolene, and her 1-year old daughter

• Juliette is the tax filer and claims Jolene and her daughter as dependents


MedicaidJuliette Jolene Daughter

Juliette

Jolene

Daughter

✔ ✔ ✔

✔

✔

✔✔

3

1

3


Household Size for Pregnant Women

• For premium tax credits, a pregnant woman

counts as one person.

• For Medicaid, Tennessee counts the woman

plus the number of children she expects to

have for her household only.

10/8/2014

Income and Household Changes Can Affect

Eligibility and/or Amount of Assistance

• Increase or decrease in income

• Household changes:

– Birth or adoption of child

–Marriage, divorce or legal separation

– Death of family member

– Family member no longer eligible to be claimed as

tax dependent

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Take a Quick Break!!!

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TennCare

10/8/2014

Applying for TennCare

• Only exceptions are:

• Presumptive Eligiblity (PE) program*

• CHOICES long-term care program

• Medicare Savings Programs (QMB, SLMB, QI).

10/8/2014

• Tennessee requires nearly all applicants for

TennCare/Medicaid to apply through the

federal marketplace.

*PE is only available for pregnant women, women with breast or cervical cancer, and newborns.

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Timeline (by law)

• Disability-related categories - 90 days

• Non-disability categories - 45 days

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TennCare Categories

• Children

• Pregnant women

• Parents and caretaker relatives

• Disability-related categories/Medicare folks

• Women with breast or cervical cancer

• Others (Former Foster Children and Emergency TennCare)

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Children

Every child is eligible for something!!

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Newborns

• TennCare Deeming

• CoverKids Deeming

• Newborn Presumptive Eligibility (NPE)

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TennCare Deeming

• For moms on TennCare, the child is deemed

eligible for TennCare for 1 year.

• The coverage starts on the date of birth.

• Call Tennessee Health Connection to enroll

child (1-855-259-0701).

10/8/2014

CoverKids Deeming

• For moms on CoverKids, the child is deemed

eligible for CoverKids (regardless of whether

the child is eligible for TennCare) for 1 year.

• Coverage starts from the date the mother

enrolled in CoverKids.

• Call CoverKids to enroll child (1-866-268-

5437).

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Newborn Presumptive Eligibility

(NPE)• For babies (12 months and younger) born to

mothers on private insurance or no

insurance

• Effective date of coverage is the date of

application.

10/8/2014

How to apply for NPE:• Qualified hospitals can enroll eligible newborns in

TennCare while parents complete a full TennCareapplication.

• Parents can also call Tennessee Health Connections to enroll a child in presumptive eligibility.

• Child remains eligible until a final eligibility determination is made on the full application.

• Parents must still do an application on the Marketplace.

10/8/2014

Children – Coverage Categories

• TennCare Medicaid

• Medically Needy

Spend Down

• CoverKids / CHIP

• TennCare Standard

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Children – TennCare Medicaid

Children up to age 19 can get TennCare.

TennCare for Children Income Limits

HH Size 1 2 3 4 5 6 7

<1: 200% FPL 1945 2622 3298 3975 4652 5329 6005

Child 1-5:

147% FPL

1429 1927 2424 2922 3419 3917 4414

Child 6-18:

138% FPL

1342 1809 2276 2743 3210 3677 4143

10/8/2014

Medically Needy Spend Down

• Covers kids up to age 21 and pregnant women

with income too high for other categories and

high medical expenses.

• Apply on the Marketplace.

• Follow-up with Tennessee Health Connection.

10/8/2014


• The FFM application asks: “Do you want help

paying for medical bills from the last 3

months?” Click “Yes.”

• If the eligibility notice does not say the child

might be eligible for TennCare, click the box in

the section titled “Full Medicaid

determination.” Then, press “Send to

Medicaid.”

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• Monthly household income must be below

the following limits after subtracting allowable

medical expenses.

Spend Down Income Standards

Household

Size

1 2 3 4 5 6 7

Income 241 258 317 325 392 408 467

10/8/2014


Example

Monthly income: $3500

Household size: 2

Spend Down Income Standard: $258

You need around $3242 in medical bills.

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Medically Needy Spend DownWhat Counts?

• Bills incurred during month of application or three previous months.

• Older medical bill(s) if paid during month of application.

• Bills from the whole family.

Coverage starts from the date of application or

when the spend down amount is reached.

10/8/2014


What Counts?

• Health insurance premiums (for 4 months).

• Transportation to and from health services

(at least 47 cents/mile*).

• Over the counter meds.

• Vision, dental, and hearing aid services.

• Medical equipment, supplies.

10/8/2014

*Based on 2013 DHS Guidelines. At that time, DHS was using the state

employee mileage reimbursement rate.

Spend Down Resource Limits

Spend Down Resource Standards

Household Size 1 2 3 4 5 6 7

Resource Limit 2000 3000 3100 3200 3300 3400 3500

Spend Down is not a MAGI category

(for now) so resource limits still apply.

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CoverKids

• Kids under 19 can get coverage under the

state’s CHIP program, called CoverKids.

• Cannot have other coverage.

• Apply at www.covertn.gov.

CoverKids Income Limits

HH Size 1 2 3 4 5 6 7

255% FPL 2480 3343 4205 5068 5931 6794 7656

10/8/2014

TennCare Categories

• Children

• Pregnant women





10/8/2014

Pregnant Women


• Presumptive Eligibility (PE)

• Medically Needy Spend Down

• CoverKids

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Pregnant Women – TennCare Medicaid

Pregnant women can get TennCare below 200% FPL.

Pregnant Women Income Limits

HH Size 2 3 4 5 6 7

<1: 200% FPL 2622 3298 3975 4652 5329 6005

A pregnant woman’s household includes the expected child(ren), but

the expected child(ren) do NOT count in the household of other

members of the pregnant woman’s household.

10/8/2014

Presumptive Eligibility

• To get onto TennCare immediately, women

can go to their local health department to get

“presumptive eligibility.”

• Must apply for Marketplace coverage before

the end of the month following the month of

application.

• Coverage should continue until TennCare

eligibility determination.

10/8/2014

Pregnant Women and

Presumptive Eligibility

Pregnant women SHOULD

NOT lose presumptive

eligibility if they have a

pending application with

the FFM. Contact TJC if this

happens.

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Medically Needy Spend Down for

Pregnant Women

• MN Spend Down also covers pregnant

women with income too high for other

categories & high medical expenses.

• Same eligibility rules as for children.

• Use the same application tips as for children.

10/8/2014

CoverKids for Pregnant Women

• Pregnant women can also get access to health

insurance through CoverKids.

• Cannot have other maternity coverage.

• State policy calls for “fast track” enrollment for

pregnant women on CoverKids.

10/8/2014

CoverKids Income Limits

HH Size 1 2 3 4 5 6 7

255% FPL 2480 3343 4205 5068 5931 6794 7656

Healthy TN Babies

• Undocumented pregnant women are eligible

for maternity coverage through CoverKids.

– Prenatal

– Delivery

– 60 days post partum

• Apply at www.covertn.gov.

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TennCare Categories

• Children

• Pregnant women





10/8/2014

Parents and Caretaker Relatives


• Transitional TennCare

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Parents & CRs: TennCare Medicaid

• TennCare for parents or caretaker relatives of

children under 18.

• “Caretaker relative” is a relative of the child

(Uncle, Grandmother, etc.) who provides

primary care for the child.

• Apply on the Marketplace.

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Parents and CRs: Income

Parents and CR Eligibility

Household Size 1 2 3 4 5 6 7

Income Limit 1,066 1,394 1,693 1,966 2,218 2,453 2,672

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TennCare Categories

• Children

• Pregnant women



• Elderly



10/8/2014

Scenario: Deacon and Megan • Megan and Deacon have 2 kids: Loretta (12) and

Kenny (1).

• Deacon makes $5100/month.

• The family has a house and 2 cars, and $3000 in savings – these are their only resources.

• The family is all insured through Deacon’s work, but the deductible and out-of-pocket maximum are very high, and the insurance doesn’t cover certain medicines.

• Loretta and Kenny both have high medical needs, and need to go to Erlanger every week for therapies.

• In mid-April, the family met the out-of-pocket maximum.

• On July 7th, the family applied for TennCare, and were denied. They sent it on to TennCare for review, but never heard back.

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What is

everyone

eligible for?

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Step 1: Quick ScreenQuick mental screen: who are we looking at?

Children

Pregnant women

Parents/Caretaker Relatives

Folks with disabilities and Medicare recipients

Women with breast/cervical cancer

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Step 2: HouseholdWhat is the household size for each person for TennCare purposes?

Counted in HH (for Medicaid)

Megan Deacon Loretta Kenny

Megan

Deacon

Loretta

Kenny

✔ ✔ ✔

What is the household size for each person for Marketplace purposes?

Same household counting as above.

✔

✔ ✔ ✔✔

✔ ✔ ✔✔

✔ ✔ ✔✔

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Step 3: IncomeIncome for household of 4 is $5100/month.

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So who’s eligible for what?

• Megan and Deacon

– Can buy insurance at full price on FFM, but aren’t

eligible for TennCare or PTCs.

• Loretta and Kenny

–Maybe Medically Needy Spend Down

What else do you need to know?

What does the family have to “spend down” to?

$325

Need $4775 in medical bills10/8/2014

Resources? Medical expenses?


Resources?

The family has one house, 2 cars, and $3000 in savings.

• Car #1 has a NADA Used Care Guide book value of $3900.

• Car #2 has a NADA Used Care Guide book value of $2100.

But, you find out that they still owe $2400 on the second car – so there is no equity!

10/8/2014

Medically Needy Spend DownMedical bills?

You ask the family to list their medical expenses. They tell you:

• Hospital visit for Deacon on April 2nd: $1500

• Hospital visit for Kenny on April 14th: Family paid $1000, insurance paid $3000

• Hospital visit for Loretta on January 8th: $4000

• Diapers for Kenny: $100/month

• Pediasure for Kenny (prescribed by doctor, but insurance won’t pay for it): $200/month

What counts?

…what else could there be?

$3300

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Remember: travel and current health insurance

premiums count! So you dig a little deeper…

• The family pays $300/month for their monthly

premiums ($1200 for 4 months)

• Every week, the family drove 120 miles round-

trip to Erlanger. (120 x .47 = $56.40/week, or

about $900 for 4 months)

$3300 + $1200 + $900 = $5400!

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…But… They already applied…

• Now what should they do?

– Appeal! Tell them on the phone that you believe

the children are eligible for Medically Needy

Spend Down.

– Gather bills and proof of application so you’re

ready if TennCare asks for it.

• If the children have severe intellectual or

developmental disabilities, they should get on

the DIDD waiting list.

10/8/2014

Practice Tips• Remember to ask about resources for

Medically Needy Spend Down!

– The first car (the more expensive one) almost never counts.

– And if the family has cars, ask if they are leased or if they still owe money on them.

• Make sure to look at date of service, not the statement date on the bills.

• Parents’ bills count, too!

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TennCare Categories

• Children

• Pregnant women


• Disability-related categories



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Disability Categories• Not based on MAGI!

• The Marketplace will not determine eligibility for these categories.

• Extremely vulnerable with great risk of eligibility going unidentified.

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Don’t worry.

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Disability Categories

• SSI

• Pickle

• Disabled Adult Child

• 1619(b)

• DIDD

• CHOICES

• Institutionalized

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Important Terms

Basic SSI Eligibility

• Full benefit amount for individual is $721.

• For children under 18, parents’ income

counts, though there are significant earned

income disregards.

• Tip: If children with disabilities are turned

down for financial reasons, they should

reapply at age 18.

10/8/2014 See Toolkit page 13

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Basic SSI Eligibility

• Resources below $2,000 for individual, $3,000

for couple, excluding homestead and one car.

• Parents’ resources count for children under 18

with some disregards.

• Apply through SSA: 1-800-772-1213



• SSI

• Pickle


• 1619(b)

• DIDD

• CHOICES


10/8/2014

Pickle – Categorical Requirements

• Pickle covers some people with disabilities

who were eligible for SSI and Social Security

in the same month.

• Disregards cost-of-living adjustments.

• Number of people eligible increases every

time there is a COLA.

• Simple screening.


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Pickle – Screening Questions

• Are you now receiving a Social Security

check?

• After April 1977, did you ever get an SSI

check at the same time that you got Social

Security, or did you get SSI in the month just

before your Social Security started?

• What is the last month in which you

received SSI?


Pickle - Income

• Multiply current Social

Security income by

corresponding number

on chart.

• “Pickled” income must

be below SSI limit

($741, includes $20

disregard).

• Must meet SSI resource

limits. 10/8/2014

Clark

• Clark started receiving SSI at age 11.

• He lost SSI at age 16 when his father retired

and he started getting Social Security based

on his father’s work history.

• He got both SSI and SSDI in May 2011.

• His only income is his SSDI check of $769.

• He has no resources.


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33

Clark

$769 x .935 = $719.02

Since his “pickled”

income is less than SSI

limit of $741, he is

eligible for TennCare in

the Pickle category.


Spotting Potential Pickles

• People may have overlap when they are first

approved for SSDI.

• May also have overlap if they are getting SSI

then something triggers Social Security

benefits (e.g., parent retiring before child is

18).

• If institutionalized, individual may be eligible

for SSI without knowing it.


Pop Quiz!

Where do you apply for Pickle?

• Apply on the Marketplace and appeal the

decision.

• Call Tennessee Health Connection.

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34


• SSI

• Pickle


• 1619(b)

• DIDD

• CHOICES


10/8/2014

DAC (Disabled Adult Child)Individuals with disabilities who

• used to receive SSI,

• lost SSI because of SSDI income based on a

parent’s work history.

* DAC is also known as CDB (childhood disability beneficiary).


DAC – Categorical EligibilityScreening questions:

• Were you diagnosed with a disability or blindness before age 22?

• Did you lose SSI after age 18?

• Did you lose SSI after July 1, 1987?

• Did you lose SSI because you started getting SSDI based on a parent’s work history or because your SSDI payment was increased?


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DAC – Income / Resources

• If yes to all these questions, all SSDI income

based on a parent’s work history is not

counted.

• DAC must not have other income that puts

them over the SSI limit.

• DAC must meet SSI resource requirements.


Tod

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Tod

• Tod is a 51 year-old with spinal muscular

atrophy, a degenerative neurological disease.

• He started receiving SSI at age 21.

• When his dad retired in 2010, he got SSDI

based on his dad’s work history ($1,300 per

month) making him ineligible for SSI.

• He has no resources.

Is he eligible for TennCare?


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Where to Apply for DAC

• If an enrollee seems to be eligible for DAC,

have them apply through the Marketplace and

call Tennessee Health Connection.

• Also check with Social Security to make sure

their benefits are coded correctly.

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• SSI

• Pickle


• 1619(b)

• DIDD

• CHOICES


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Halfway through disability categories!

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1619(b)

Individuals who:

• meet SSA disability criteria,

• are receiving SSI but are going to lose it

because of their work income, and

• have medical need such that they need

TennCare coverage to be able to work.

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1619(b) – Income and Resources

• Income - In 2014, the income limit for this

category is $36,313 (could be even higher

depending on medical expenses).

• Resources – Must meet SSI resource limits.

• Discuss with Social Security Administration.

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• SSI

• Pickle


• 1619(b)

• DIDD

• CHOICES


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DIDD Waiver

• Categorical: For individuals with intellectual

disabilities with an onset before age 18.

• Income: Only applicant’s income counts.

Income limit is $2,130.

• Resources: Only applicant’s share of resources

count. Resource limit of $2,000, excluding

homestead and car.


DIDD Waiver

• Closed for new enrollment, extremely long

waiting list.

• Worth being on waiting list.

• Call DIDD to apply. 1-866-249-0711



• SSI

• Pickle


• 1619(b)

• DIDD

• CHOICES


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CHOICES – Categorical

• Must meet CHOICES medical criteria.

• CHOICES medical eligibility is based on ability

to do activities of daily living (ADLs).

CHOICES 1:Nursing home careCHOICES 1:Nursing home care

CHOICES 2: Full array of HCBSCHOICES 2: Full array of HCBS

CHOICES 3: At-risk group, limited HCBSCHOICES 3: At-risk group, limited HCBS


CHOICES Income and Resources

• Income: Only the applicant’s income counts. Monthly income must be below $2,130.

• Resources: Applicant’s share of resources must be below $2,000 excluding homestead and car.

–Community spouse can have higher share of resources


Where to Apply for CHOICES

• To apply for CHOICES, call your local Area

Agency on Aging and Disabilities if you are not

already on TennCare.

• If you are on TennCare, contact your MCO.

• If turned down for CHOICES based on not

meeting medical criteria, appeal.


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40


• SSI

• Pickle


• 1619(b)

• DIDD

• CHOICES


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Institutionalized TennCarePeople who

• Have been institutionalized more than 30 days,

– Institution = nursing home, residential treatment center, hospital, ICF/ID

• have income below $2,163 per month (only applicant’s income counts), and

• resources below $2,000.


Review: Disability Category Red Flags

• SSI – Very low income individual with

disabilities

• Pickle – Received or eligible for SSI and Social

Security benefits in same month

• DAC – Lost SSI due to SSDI based on parent’s

work history

• 1619(b) – Losing SSI due to work income

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Disability Category Red Flags

• DIDD – Intellectual disability

• CHOICES – Need assistance with activities of

daily living

• Institutionalized – In medical institution for

30+ days

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Tips for People with Medicare

• Some people with Medicare may also be

eligible for TennCare.

• Particularly, look at Pickle. More people

become eligible every year. Most don’t even

know to apply.

• People who need long-term care may also be

eligible for CHOICES.

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Medicare Savings Programs

• Medicare Savings Programs (QMB, SLMB, and

QI) help pay Medicare costs.

• See Toolkit Page 16.

• Apply using Long-Term Services and Supports

/ MSP application form.

• http://www.tn.gov/tenncare/forms/LTSSMedi

caidApplication.pdf

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TennCare Categories• Children

• Pregnant women





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Breast or Cervical Cancer

• Covers uninsured women under 65 in active

treatment for breast or cervical cancer.

• Must not have access to other insurance that

covers cancer treatment.

• Must have income at or below 250% FPL.

• No resource limit.

*For breast cancer, must be over 40 and under 65.

*For cervical cancer, must be over 21 and under 65.

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• Applicants must go to the county health

department to get “presumptive eligibility” for

TennCare.

• Still need to promptly apply for TennCare on

the Marketplace. Presumptive eligibility

continues while that application is pending.

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Breast and Cervical Cancer

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43

TennCare Categories

• Children

• Pregnant women





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Coverage for Individuals

Formerly in Foster Care

Coverage is available for individuals who:

– Left foster care at 18 years old or older, AND

– Are aged 26 and younger.

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Former Foster Children

• DCS is maintaining eligibility for kids aging out

of foster care now.

• Former foster children must apply through the

FFM.

• Little to no outreach to let them know about

eligibility.

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Emergency Medicaid

• Emergency Medicaid is supposed to cover

undocumented immigrants AND immigrants in

the 5-year bar during emergency situations.

• Currently no real way to apply in TN, but start

on the Marketplace.

• Follow up with THC.

– Hospital record(s), proof of income, proof of

application, etc.

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TennCare Categories

• Children

• Pregnant women





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Recertification• Recertification is coming!!!

• Anyone whose TennCare eligibility needs to be reevaluated, since October 1, 2013.

• This will affect over 1M TennCare enrollees.

–Will be evaluated under

ACA standards

–Will need help navigating

the TennCare enrollment

process

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TennCare Standard

• Children under 19 that are on TennCare

Medicaid but become ineligible can

sometimes roll into TennCare Standard.

• No access to employee health insurance.

• Eligible if they are either

–Below 212% FPL, or

–have a qualifying health condition

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Transitional TennCare

For low-income families who lose TennCare due

to income. Details under new eligibility rules are

still unclear.

• Categorical: Must have been covered in

TennCare for at least 3 of the last 6 months.

• Income: Must have income below 185% FPL.

• Transitional TennCare available to family for

up to 12 months.

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Filling the Knowledge GAPGAPGAPGAP

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What is THE GAPTHE GAPTHE GAPTHE GAP?• TennCare was supposed to expand last January to

cover all Tennesseans who cannot afford health insurance.

• The Governor chose NOT to take the Federal dollars to finance the expansion

• If a client cannot afford health insurance and is not eligible for existing TennCare, the client is in the Gap.

• FYI: Kentucky lawmakers TOOK the federal dollars. All residents in Kentucky have health care coverage.

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THE GAPTHE GAPTHE GAPTHE GAP, Illustrated

??What can you do for a client in the Gap??

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How to manage THE GAPTHE GAPTHE GAPTHE GAP

SHARE the story: StoryBank Hotline 615-900-GAP3• Sharing stories helps us to learn more about what is happening to real

people who fall into the Health Coverage Gap.

• We can use this information to explain health care access problems to legislators, to the media, and to the larger public.

CALL your state legislators• Who are your STATE legislators? www.capitol.tn.gov/legislators/

HEALTH ASSIST: to find local free or low cost care• 1-800-269-4038

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THE GAP THE GAP THE GAP THE GAP Message

• Working families are suffering without health coverage or the financial security that it provides.

• Tennessee’s health care infrastructure that we all rely upon is at risk.

• The state is STILL losing $2.7 million DAILY.

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Questions? Comments?

Let ‘em loose!

10/8/2014

Thank you for being here today.

“Of all the forms of inequality, injustice in

health care is the most shocking and

inhumane.”

-Martin Luther King, Jr.

www.facebook.com/tnjustice

www.twitter.com/tnjusticecenter

[email protected]

10/8/2014

navigating tenncare & the marketplace · navigating tenncare & the marketplace tennessee...

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