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Navigating TennCare:Household Counting, MAGI
Income, and Redetermination
8/10/2016
Chris Coleman, Staff AttorneyRob Watkins, Staff Attorney
Agenda
8/10/2016
• Household counting (45 min)• MAGI Income (45 min)• Break (15 min)• Redetermination (45 min)• Q & A (30 min)
Resources
8/10/2016
TJC Toolkit for TennCare and the Affordable Care Act
8/10/2016
https://www.tnjustice.org/wp-content/uploads/2014/10/2016-06-01-TJC-
Toolkit.pdf
Keila Franks, Training [email protected]
615-255-0331, ext. 222Toll Free: 1-877-608-1009
Household Counting
8/10/2016
Why Counting Household Size is Important:
Eligibility for any Insurance Affordability Program (Premium Tax Credits, TennCare, CoverKids) is based on household income.
To determine household income, you must know
• Whose income counts?
• What counts as income?
8/10/2016
Why Counting Household Size is Complicated:
• Household size is an individual determination, so people living in the same house could have different household sizes
• Different rules for some categories of TennCare eligibility
• Different rules depending on tax filing status
8/10/2016
3 Types of Household Counting Rules:
1. MAGI
2. Non-MAGI
3. SSI Disability-Related
8/10/2016
Household Counting for MAGI Categories
8/10/2016
What is MAGI?
MAGI is a methodology for how income is counted for purposes of:
• Premium Tax Credits
• Cost-Sharing Subsidies
• CoverKids
• Some TennCare eligibility categories
8/10/2016
Whose TennCare eligibility is based on MAGI?
MAGI Non-MAGI
Parents and Caretaker Relatives Anyone for whom Medicaid agency not required to make income determination (e.g., SSI, federal foster care or adoption assistance recipients)
Pregnant Women CHOICES
Children Spend-down
New “adult group” (if Tennessee passes Insure Tennessee)
Medicare cost-sharing programs
Breast and cervical cancer
SSI-related categories (DAC, Pickle, 1619(b))
8/10/2016
Household Size Under MAGI Rules
Step 1: What is the applicant’s expected tax filing status?
• Three categories of individuals:
– Tax filers not claimed as tax dependents
– Tax dependents
– Non-filers and not claimed as tax dependents
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The MAGI household will ALWAYS be either:
1. Tax filing unit
2. Parents, minor children, and minor siblings living together
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Child(ren)• For the Marketplace, an individual must be
under 19 to be a “qualifying child” in the HH.
– Exception: Full time student under 24
• For TennCare, an individual must be under age 19 to be considered a “child” in the HH.
– Exception: Full time student under 21
8/10/2016
NOTE: We’re talking about who is counted in the household. Being counted in the household does not trigger categorical eligibility for TennCare.
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 TennCare: 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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Household Size for TennCare: Non-filer, Not Claimed as a Dependent
Household size = Parents, minor children, and siblings living together
• Adults: Individual plus spouse and minor children (including step-children) living with the individual
• Children: Child plus minor siblings and parents (including step-parents) living with child.
8/10/2016
Household Size for TennCare: Tax Dependent
Household size = household of the tax filer claiming the dependent (tax filing unit),
unless . . .1. Tax dependent is not minor child or spouse of tax
filer
2. Tax dependent is a minor child living with both parents who are unmarried
3. Tax dependent is a minor child claimed as a tax dependent by a non-custodial parent
8/10/2016
8/10/2016Page 4 of the TJC Toolkit
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 Size8/10/2016
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 Medicaid
Rayna Teddy Maddie Daphne
Rayna
Teddy
Maddie
Daphne ✔
✔
✔
✔
✔ ✔
✔
✔ ✔
✔
✔ ✔
✔ ✔ ✔✔ 4
4
4
4
Medicaid Household Size8/10/2016
Conrad≠James Family (after divorce)• Rayna lives with both
daughters and files taxes as a single individual
• Teddy claims girls as tax dependents
Lisa
Son
Father
Counted in HH HH Size for MedicaidRayna Maddie Daphne Teddy
Rayna
Maddie
Daphne
Teddy
✔
✔✔
✔✔
1
3
3
✔
✔
✔ ✔ ✔
3
Medicaid Household Size8/10/2016
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
Counted in HH HH Size for MedicaidRayna Maddie Daphne Teddy
Rayna
Maddie
Daphne
Teddy
✔
✔
✔✔
2
2
3
✔
✔ ✔ ✔
2
✔
Medicaid Household Size8/10/2016
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
Counted in HH HH Size for MedicaidJuliette Jolene Daughter
Juliette
Jolene
Daughter
✔ ✔ ✔
✔
✔
✔✔
3
1
3
Medicaid Household Size8/10/2016
Household Changes Can Affect Eligibility and/or Amount of Assistance
• 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
– Minor turning 18
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Married Couples• For the Marketplace, married couples
generally must file a joint tax return to receive premium tax credits and cost-sharing reductions.
• For TennCare, married couples who live together are counted in the same household regardless of whether they file joint or separate tax returns.
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Pregnant Women
• For the Marketplace, a pregnant woman counts as one person.
• For TennCare, Tennessee counts the woman plus the number of children she expects to have for her household only.
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What’s Next? Counting Income!
Once an individual’s MAGI household is clear, a second determination must be made as to whether or not to include the income of each household member in the calculation of the household income.
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Income
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Why Household Income MattersNecessary to convert income to a federal poverty level (FPL) standard.
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Household
size100% 138% 200% 250% 400%
1 $11,880 $16,394 $23,760 $29,700 $47,520
2 $16,020 $22,108 $32,040 $40,050 $64,080
3 $20,160 $27,821 $40,320 $50,400 $80,640
4 $24,300 $33,534 $48,600 $60,750 $97,200
5 $28,440 $39,247 $56,880 $71,100 $113,760
What Constitutes Income?
General Definition:“Except as otherwise provided in this subtitle, gross income means all income from whatever source derived…” (emphasis added)
26 U.S. Code Section 61
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What Constitutes Income?
General Definition:“… including (but not limited to) the following items…”
26 U.S. Code Section 61
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• (1) Compensation for services, including fees, commissions, fringe benefits, and similar items;
• (2) Gross income derived from business;
• (3) Gains derived from dealings in property;
• (4) Interest;
• (5) Rents;
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What Constitutes Income?
What Constitutes Income?
• (6) Royalties;
• (7) Dividends;
• (8) Alimony and separate maintenance payments;
• (9) Annuities;
• (10) Income from life insurance and endowment contracts;
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What Constitutes Income?
• (11) Pensions;
• (12) Income from discharge of indebtedness;
• (13) Distributive share of partnership gross income;
• (14) Income in respect of a decedent; and
• (15) Income from an interest in an estate or trust.
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This means…
Money received is considered taxable income unless the code says it isn’t.
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MAGI Income
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What is MAGI?• A methodology for how income is counted for:
• Some TennCare eligibility categories• CoverKids eligibility• Advanced Premium Tax Credits (APTC)• Cost-Sharing Reductions (CSR)
• Based on federal tax rules for determining adjusted gross income (w/ some modification)
• No resource test or disregards • except a 5% income disregard for those who
would otherwise be ineligible – does not apply to APTC/CSR
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Calculating MAGI
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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)
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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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Step 2: Adjusted Gross Income (AGI)
Gross Income MINUS 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)
TJC Toolkit page 68/10/2016
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)
TJC Toolkit page 68/10/2016
Adjusted Gross Income – 1040 (Lines 23-37)
See IRS Publication 17 Your Federal Income Tax
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Step 3: from AGI to MAGIModified 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
TJC Toolkit page 68/10/2016
Special Rule for Tax Dependents
8/10/2016
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: 6,300/yr in earned or $1,050/yr in unearned
with some key exceptions;
• See IRS Publication 929 Tax Rules for Children & Dependents
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Key Exceptions: Tax-Filing Triggers
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• Some Church wages
• Self-Employment net earnings of $400 or more.
• Uncollected Social Security Medicare taxes on tips
See IRS Publication 17 for more information.
Income of Tax Dependents
Maddie & Daphne make $3,050 apiece for playing at an awards show.
Is this income part of the household’s MAGI?
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Income of Tax Dependents
ANSWER: Need More Info!
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Social Security Benefits& Supplemental Security
Income (SSI)
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Social Security PaymentsTitle II Social Security is NOT a need-based Program. It is based on someone’s work history. Title II Social Security can be subject to income tax.
Types Are:• Retirement Benefits
• Social Security Disability Insurance
• Widow(er) Benefits
• Survivor’s Benefits
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Supplemental Security Income (SSI)SSI is called a "means-tested program,” meaning it has nothing to do with work history, but rather strictly with financial need.
• The income limit is $733 for individuals and $1,100 for couples.
• Resource limits are $2,000 for individuals and $3,000 for couples.
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SSI & SSDI Differences
Supplemental Security Income (SSI) – low income people over 65 or disabled.• NOT subject to income tax;• Income limits are $733 for individuals and $1,100 for couples;• Automatic enrollment in TennCare.
Social Security Disability Insurance (SSDI) –under 65 and based on someone’s work history.• May be subject to income tax;• Can be based on the person’s, parent’s or spouse’s prior work
history;• Not automatically enrolled in TennCare
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SSI & SSDI Benefits
Which one is it?
SSI benefits are paid on the first day of each month*.
*If the first of the month is on a Saturday, Sunday, or legal holiday, the benefits will be paid on the banking day before.
8/10/2016
SSI & SSDI Benefits
Which one is it?
SSDI benefits are paid on:
• After 1977 on the 2nd, 3rd or 4th
Wednesday of the month.
• Before 1977 on the 3rd day of the month.
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Key Questions to Ask
How much is your check each month?
If over $733 it is probably NOT SSI
When do you receive your check?If on or before the 1st of the month, it is
probably SSI.
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Tax Filers, NOT claimed as Dependents
ALL Social Security benefits are included in the MAGI calculation.• Retirement Benefits• Disability (SSDI)• Survivors Benefits• Widow(er) Benefits
NOTE: Does NOT include Supplemental Security
Income (SSI)8/10/2016
Special Rule for Tax Dependents
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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: 6,300/yr in earned or $1,050/yr in unearned
with some key exceptions;
• See IRS Publication 929 Tax Rules for Children & Dependents
8/10/2016
Tax Dependents Receiving Social Security Benefits
A dependent’s income ONLY counts toward the household income if the dependent is REQUIRED to file taxes.
• You will need to calculate the taxable amount of Social Security to determine if the dependent is required to file a tax return.
• IRS Publication 915 Social Security & Equivalent Railroad Retirement Benefits
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Tax Dependents Receiving Social Security Benefits
How much of the benefit is taxable?• Generally, if the only source of income is Social
Security then none of it will be taxable.• Considered Unearned Income• No one pays federal income tax on more than 85
percent of his or her Social Security benefits;
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Tax Dependents Receiving Social Security Benefits:
FAST check
Social Security benefits*/2+ All other income*
If less than $25,000 (single)If less than $32,000 (married)
• Then: None of the benefit is taxable.• If over limit, need to calculate taxable amount.
*If married, include spouse’s income and benefits
8/10/2016
RECAP: Social Security Benefits
Tax-Filer Not Claimed as a DependentCount the ENTIRE amount
Tax DependentOnly include taxable amount to see if
the dependent is required to file taxes.If not, EXCLUDE the entire amount.
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Income Gray Areas
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Government Benefits
General Rule:
If the benefit is based on need, then it is NOT taxable.
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Government Benefits
• Supplemental Security Income (SSI)• Veteran’s Benefits (Not Military Retirement Pay)
• State Assistance (Families First)• Food Assistance• Housing Assistance• Energy & Utility Assistance
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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 2016) without triggering a gift tax return (grantor files).
For MAGI
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What About Items Like:
Unemployment – all payments are taxable.
Worker’s Compensation– is NOT taxable.
For MAGI
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What About Items Like:
Child Support• Payor – Not deductible • Recipient – Not taxable
Alimony
• Payor – Can deduct
• Recipient – Taxable
For MAGI
8/10/2016
Whose eligibility is based on MAGI?
MAGI Non-MAGIParents and Caretaker Relatives Anyone for whom Medicaid agency
not required to make income determination (e.g., SSI, federal foster care or adoption assistance recipients)
Pregnant Women CHOICES
Children (1 through 18) Medically Needy Spend-Down
Insure Tennessee coverage group Medicare Savings Programs (MSP)
APTCs/CSRs
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What is the time period?
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Issue TennCare/CoverKidsMAGI
APTCs & CSRsMAGI
MonthlyIncome
ORAnnual Income
Current Month
OfApplication
Projected Annual Income
Let’s Practice!
8/10/2016
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 royalities
from 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
8/10/2016
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 royalities
from 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/yr8/10/2016
Practice Tips:Check Dependents – Only count their income if required to file taxes. Check exceptions.
MAGI – Don’t need to consider resources/assets.
Tax Credits vs. TennCare – Estimated Yearly vs. Month of application income.
IRS Publication 17 Your Federal Income Tax
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MAGI Income Review
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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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TennCare Redetermination
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What the law requires
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Periodic Redetermination of Medicaid Eligibility
By federal law, all Medicaid (TennCare) enrollees must have their eligibility redetermined every 12 months.
42 CFR 435.916(a) and (b)
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Periodic ReviewPeriodic 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.
42 CFR 435.916(a)
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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 435.916(a)
8/10/2016
According to the TennCare Rules:REDETERMINATION shall mean the process by which [DHS] evaluates the ongoing eligibility status of TennCare Medicaid and TennCare Standard enrollees. This is a periodic process that is conducted at specified intervals or when an enrollee’s circumstances change. The process is conducted in accordance with TennCare’s, or its designee’s, policies and procedures.
8/10/2016
TennCare Rule 1200-13-13-.01
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”)
• Send to enrollees notices that are pre-populated with any information already available to the state.
• Afford enrollees an opportunity to provide any missing information or documentation.
• Provide assistance – in person & by phone.
8/10/2016
And…• Assess enrollees’ eligibility in all open
categories of TennCare.
• 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.
8/10/2016
The Enrollee is Required to…• Keep TennCare informed of any changes in
contact information.
• Report changes in income and/or household composition.
• Respond to redetermination notices within 30 days.
• Provide supporting documentation, as requested by the state.
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Process
8/10/2016
Process• This year’s redetermination process looks
different than in previous years.
• DHS offices are said to be helping fill out and fax redetermination packets.
• Enrollees do not have a case worker they can contact.
• Tennessee Health Connection (TNHC) can help with basic questions about the redetermination packet.
8/10/2016
Three Phases• Phase 1: SNAP match (May & September
2015)
• Phase 2: confirmation mailing (October-December 2015)
• Phase 3: redetermination packet (December, January & present)
8/10/2016
Phase 3• This step requires enrollees to respond to
extensive requests for information (RFI).
• It will affect individuals due for redetermination, whose eligibility was not redetermined in Phase 1 or 2.
• Failure to document eligibility or respond to notices will result in termination of TennCare.
8/10/2016
Phase 3• Phase 3 started on December 14, 2015 with a
pilot group of 10,000.
• In February, the state halted redetermination.
• In June, the state resumed the process.
• An additional group of 90,000* people will receive redetermination packets between June and August 2016.
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*Individuals enrolled in Long Term Services & Supports will not be included as part of the 90,000 people. TennCare said that LTSS redeterminations will begin in August 2016.
Challenges in Completing Phase 3
8/10/2016
These Challenges Are:
• Enrollees have households larger than 2 people.
• Enrollees may not receive the redetermination packet.
• Enrollees may not understand the redetermination packet.
• Enrollees may fail to take timely action.
8/10/2016
Enrollees have households larger than 2 people
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Phase 3 NoticeBarcode on bottom, left-hand side is unique to each redetermination packet & on every page.
8/10/2016
Do NOT make copies of the redetermination packet to be used
for members outside of the household.
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Enrollees May Not Receive the Redetermination Packet
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Enrollees May Not Receive the Redetermination Packet
• At least one third are likely to have moved since their eligibility was last determined. http://blogs.census.gov/2012/12/10/america-a-nation-on-the-move/
• Even if they reported a change in address, they can’t be sure the new address made its way into the system.
8/10/2016
Change of Address Form• TennCare Change of Address Reporting Form
– English: http://tn.gov/assets/entities/tenncare/attachments/ChangeOfAddressForm.pdf
– Spanish: http://tn.gov/assets/entities/tenncare/attachments/ChangeOfAddressFormSP.pdf
• TJC recommends reporting changes by fax. Save fax receipt.
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Lost Redetermination PacketsIf an enrollee loses their Redetermination Packet, they should call Tennessee Health Connection at 1-855-259-0701. TNHC will mail a new Redetermination Packet to the address on file.
8/10/2016
Steps to Request a New Packet 1. Call TNHC and ask what address they have on
file.
2. If TNHC does not have the current address, make the change over the phone. Afterward, fax the change of address form and save the fax receipt.
3. Request a new redetermination packet. Record the date and time of the call and the name of the TNHC representative.
8/10/2016
Advocacy Tips• Save the envelope in which the
redetermination packet arrives.
• Keep track of the date TennCare says your redetermination packet is due.
8/10/2016
Enrollees May Not Understand the
Redetermination Packet
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Challenging Areas of Redetermination Packet
• Counting Household Members
• Proof of Income
• Gap-Filling Rule
• MAGI Deductions
• MAGI & Non-MAGI Categories To Be Screened
• Assistance for individuals with disabilities
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Counting Households
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Page 2 of 8
Recommended StepsStep 1– Tax Filing
• Does the enrollee file or expect to file taxes this year?
• If yes, list everyone that will be claimed as a dependent.
• If no, go to Step 2.
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Recommended Steps
Step 2– Identify Family Members
• These are family members living in the household.
• Exclude those members who file their own taxes AND are not claimed as a dependent on the enrollee’s return.
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Why This Is Important
Non-MAGI and MAGI household counting methodologies are different.
• Non-MAGI is based on immediate family members.
• MAGI is based on tax-filing unit with 3 exceptions for dependents:
– 2 unmarried parents;
– Someone other than the spouse or child of the tax-filer;
– Child claimed by a non-custodial parent.
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Proof of Income
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Page 1 of 8
Sending “Proof” of Income• Phase 3 Cover Letter references sending proof
with the packet, but it doesn’t mention what the proof should be.
• TJC recommends sending proof of the most recent 8 weeks of income, if possible (unless there’s been a change in income for the current month – attach explanation if needed).
• In most cases, eligibility is based on point-in-time income.*
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*See Gap-Filling Rule.
TJC’s Income HandoutYou can download our handout to give to enrollees from our website:
https://www.tnjustice.org/wp-content/uploads/2015/10/2016-01-13-Redetermination-Income-handout.pdf
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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).
8/10/2016
42 CFR 435.603(i)
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.
8/10/2016
Screening for the Gap-Filling Rule1. 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.
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How to Apply the Gap-Filling Rule
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Page 4 of 8 (Person 1) question #30Page 6 of 8 (Person 2) question #31
See attached.
How to Apply the Gap-Filling Rule1. 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.
2. 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.
3. Call TJC.
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Gap-Filling Rule Main TakeawayIf the individual…
1. Is categorically eligible for MAGI (e.g. parent/caretaker relative, children), AND
2. Has annualized income below 100% FPL
THEN they maintain TennCare eligibility.
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MAGI Deductions (Renewal Packet)
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Pages 4 of 8 (Person 1) and 6 of 8 (Person 2)
MAGI Deductions (IRS)
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Screening for Non-MAGI Categories
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Pages 3 of 8 (Person 1) and 5 of 8 (Person 2)
Resources: PropertyNo designation of homestead
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Appendix A, Page 3 of 4
Homestead
Enrollees May Fail to Take Timely Action
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Timeframes• 30 days to fill out and return the
redetermination packet.
• 10 days to respond to request for more information.
• 10 days from notice of termination to request an appeal with continuation of benefits (COB).
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Request for Information (RFI)
By federal law, enrollees have at least 30 days from the date of the renewal form to respond and provide any necessary information through any of the modes of acceptable submission.
-§ 435.916(a)(3)(i)(B)
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What if an Enrollee Misses the Deadline for Submission?
• 90 days from date of termination to submit the redetermination packet and additional information (if applicable) in order to be reinstated.
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Modes of Acceptable Submission
• [Website]
• Phone
• In-person (DHS county office will forward)
• Other commonly available electronic means (e.g. fax and email)
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WARNING!TennCare has said they will send termination notices to people who were included in the December and January redetermination mailings and who have not yet responded to the packet.
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What To Do When Someone Is Terminated
1. Request an eligibility appeal with continuation of benefits (COB). Save fax receipt; AND
2. If the termination was for failure to submit the redetermination packet OR supplemental documents (e.g. proof of income), then submit them within 90 days of the termination.
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Main Takeaways• Document everything.
• If terminated, appeal with continuation of benefits.
• If you think the individual is eligible under the Gap-Filling Rule, call TJC.
• If an enrollee has trouble getting assistance, call TJC.
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Resources/Assistance• Tennessee Health Connection (TNHC)
• TennCare Advocacy Program (TAP)
• DHS
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Questions & Answers
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What does TJC do?
Advocate for Tennesseans
Provide trainings
Help clients one-on-one
Join TJC for a FREE 2-day training on “Navigating TennCare”
For more information or to register, go to:
www.tnjustice.org/help/trainings
When:Monday, October 24, 1:00 PM –5:00 PM Tuesday, October 25, 8:00 AM –1:00 PMWhere: Curb Medical Learning CenterSt. Thomas West Hospital 4220 Harding Road Nashville, TN 37205
Technical Assistance• TJC will help troubleshoot complex cases that
you have not been able to resolve on your own.
• You can refer complex cases to TJC for expert case management.
Email Keila Franks at [email protected]
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What is TJC’s Independence Initiative?
• Independence helps seniors and adults with disabilities live independently
• Independence includes two areas of advocacy:
– CHOICES Long Term Services & Supports
– Public Benefit Enrollment
Public Benefit Enrollment• Goal = help 1,000 Tennessee Seniors and adults with
disabilities enroll in five core services:
1. Medicare Savings Programs (MSPs): help with paying Medicare copays and premiums
2. Medicare Part D Extra Help (LIS): help with paying for medication
3. TennCare: Tennessee’s state Medicaid health insurance
4. Supplemental Nutrition Assistance Program (SNAP): Formerly called food stamps. Help with monthly food & groceries
5. Low Income Home Energy Assistance Program (LIHEAP): help with home heating and cooling bills
Public Benefit Enrollment• We help seniors and adults with disabilities across the
entire state of Tennessee• We help with all enrollment steps from start of
application to receiving of benefits• All services are free!• Please Contact:
Jana Hall, Senior Outreach & Enrollment Coordinator
877-608-1009, ext.203 toll free
Thank you for joining us!
www.facebook.com/tnjustice
www.twitter.com/tnjusticecenter
“Of all the forms of inequality,injustice in health care is the most shocking and inhumane.”-Martin Luther King, Jr.
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