Opinion ID: 786208
Heading Depth: 2
Heading Rank: 1

Heading: TennCare Enrollment and Eligibility

Text: 6 The Tennessee Department of Health (TDH) administers the TennCare program for the State of Tennessee. Tenn.Code Ann. § 71-5-104. The TennCare program is a federal waiver plan under the Medicaid Act approved by the Secretary of Health and Human Services under 42 U.S.C. § 1315. The waiver eliminated certain requirements for eligibility for medical benefits under the Medicaid Act. 7 Under the TennCare program, Tennessee provides medical assistance to eligible persons through managed care organizations rather than through traditional fee-for-service arrangements with providers. TennCare coverage is extended to three groups of individuals: (1) existing Medicaid beneficiaries and those who meet Medicaid's financial and/or medical eligibility requirements; (2) the uninsured; and (3) the uninsurable. Tenn. Comp. R. & Regs. 1200-13-12-.02(2)(a) 2 and 3. The TennCare regulations define uninsured persons as: 8 [A]ny person[s] who as of March 1, 1993 ... did not have coverage under an individual health insurance policy or who did not have (either directly or through a family member) coverage under, or access to, employer-sponsored health insurance or to another government plan, and continues to lack this access.... 9 TENN. COMP. R. & REGS. 1200-13-12-.01(36). Persons eligible for TennCare coverage as uninsureds can enroll during periods of open enrollment. Tenn. Comp. R. & Regs. 1200-13-13-.03(1)(d). The open enrollment period continues until the program reaches 85% of the maximum enrollment cap for that year. TENN. COMP. R. & REGS. 1200-13-13-.03(1)(d). 10 The TennCare regulations define uninsurable persons as [A]ny person[s] who are unable, because of an existing medical condition, to purchase health insurance, but who meets the guidelines of the [program]. Tenn. Comp. R. & Regs. 1200-13-12.-.02(35). Persons eligible for TennCare coverage as uninsurables can enroll at any time. TENN. COMP. R. & REGS. 1200-13-12-.03(1)(b) 2. 11 To enroll in the TennCare program, an applicant must answer a series of written questions and submit the completed forms to the TennCare Bureau. The same application is used for both uninsured and uninsurable applicants. Applicants are not required to reflect on the application whether they are seeking medical insurance as an uninsured or uninsurable person. 12 The TennCare regulations state that enrollment in the program is complete when the person eligible for enrollment has selected a managed care plan from those available in the area where the person resides, the application has been approved by the Bureau of TennCare, and when any applicable premiums have been paid. Tenn. Comp. R. & Regs. 1200-13-12-.03(1). The regulations further provide that [e]nrollment shall be deemed complete retroactive to the date of the original application, if that application is approved. Tenn. Comp. R. & Regs. 1200-13-12-.01(1). This is consistent with the Medicaid regulations and waiver that require approval of medicaid coverage up to three months from the date of the approved application. 13 However, if an application is denied, the TennCare regulations require that written notice to the applicant include the following: 14 1. An explanation of the reasons for the Bureau's actions, including a brief statement of the factual basis and the rule or contract provision relied upon by the Bureau; 15 2. An explanation of the circumstances under which the TennCare applicant can request an appeal; and 16 3. An explanation of the TennCare applicant's right to submit documents or other information in support of a request for appeal. 17 TENN. COMP. R. & REGS. 1200-13-12-.11(3)(b). Furthermore, an applicant may appeal the denial of TennCare coverage within 30 days after the date of the notice of denial. TENN. COMP. R. & REGS. 1200-13-12-.11(3)(a).