Tennessee Medicaid Eligibility: What Seniors Should Know About TennCare

TennCare is Tennessee’s Medicaid program (funded by both the state and federal governments). TennCare’s goal is to pay medical bills for people who cannot afford to pay their own. TennCare covers about 20% of the Tennessee population, which includes 1.4 million people with a 12 million dollar budget. This includes 50% of Tennessee children and 50% of Tennessee births.

TennCare insurance is NOT Medicare – it is strictly a Medicaid program. While Medicare is for Tennessee senior citizens, Medicaid is for low-income Tennessee residents of all ages. Some people will be eligible for both! If you are eligible for TennCare, you will begin with TennCare Medicaid.

Click to read more about each TennCare Insurance topic:

• Medicaid Eligibility in Tennessee
• How to Apply for Medicaid in Tennessee
• Tennessee Medicaid Application
• What Does Medicaid Cover in Tennessee?
• Income Requirements for Tennessee Medicaid
• Medicare Cost Sharing Programs
• How Much Does Medicare Cost in Tennessee?
• Cost and Coverage of Medicaid in Tennessee
• Prescription Drugs with Medicaid in Tennessee
• Which Medicare Plan is Best in Tennessee?
• Which Medicaid Plan Would be Best in Tennessee?
• Dual Eligible Medicare and Medicaid Plans in Tennessee
• How to get TennCare Coverage
• For More Information About TennCare

Medicaid Eligibility in Tennessee

To be eligible for TennCare, you must:

• Be a legal Tennessee resident
• Fall below income and asset limitations. Assets include bank accounts, cars, land, etc.
• Have a certain number of people in your household.

Tennessee Medicaid eligibility is mainly for those who are under 21, pregnant, are a single parent, are unemployed or receive social security benefits, or live in a nursing home or have a private nurse. If you do already receive social security benefits, TennCare will be aware of that and you can be automatically enrolled in Tennessee Medicaid.

Are Tennessee Medicaid and TennCare the same?

TennCare is the name given to Tennessee’s Medicaid program.  The two names are interchangeable.

Is TennCare Medicaid or Medicare?

TennCare is Medicaid in Tennessee. The Medicare program is federal, so it has the same name nationwide: Medicare. Tennessee Medicaid eligibility does not affect Medicare eligibility.

How to Apply for Medicaid in Tennessee (Tenncare Application)

If you are not automatically enrolled in Medicaid and need to apply, start by gathering the following information:

• Any W2 forms or evidence of taxable income
• Social security numbers and birthdates of those in your household
• Any recent health insurance information
• Official identity, citizenship information, or alien registration information
• Employer information (name, address, phone number) for anyone in the household who is employed
• Any other income sources

After you’ve gathered as much information as you have, you can start your Tennessee Medicaid Application.

Tennessee Medicaid Application

Under the Affordable Care Act, the application process for TennCare and Tennessee’s CoverKid health care is digital. You can submit the TennCare application through the FFM (Federally Facilitated Marketplace) either digitally or by mail at any time of the year.

If you prefer, you can also apply in person at a Tennessee Department of Human Services (in any county) where a trained staff member can assist you. Click here to find one in your area. You can also apply by phone at 1-800-318-2596.

If you are disabled and need further assistance with your application, call your local Area Agency on Aging and Disability at 1-866-836-6678.

If you are asking someone else to help you with your Tenncare application, please note that only the following individuals can submit your application:

• If you are under 18, your parent or guardian
• An authorized representative, like a power of attorney
• A responsible adult relative, friend, or guardian who knows and understands your circumstances well
• A representative from your current long-term living facility

Once you apply, you will receive notice of your confirmation or denial within 45 days for low-income and 90 days for disability.

What Does Medicaid Cover in Tennessee?

Medicaid is both state and federally regulated. Under federal law, Medicaid (TennCare) is required to cover:

• Inpatient hospital services
• Outpatient hospital services
• EPSDT: Early and Periodic Screening, Diagnostic and Treatment Services
• Nursing facilities
• Home health
• Physician, health clinic, and qualified health center services
• Laboratory and x-ray services
• Emergency medical transportation

Even though these items all fall under required coverage, everyone does not have the same TennCare insurance. Your TennCare card will have a letter (A through M) on it, called a Benefit Indicator, that tells providers what kind of coverage you have.

Generally speaking, Medicaid covers:

• Specialists recommended by your primary care physician (like cardiologists and oncologists)
• Preventative care (yearly wellness visits)
• Dentalquest (dental) for those under 21
• Mental health physician and facility treatment
• Substance abuse treatment
• Transportation to health care visits
• Prescriptions from most pharmacies

If you need special long-term care, you may also qualify for CHOICES. CHOICES covers nursing facility or in-home care for those with long-term intellectual, developmental, and/or physical disabilities.

Income Requirements for Tennessee Medicaid (TennCare Insurance)

Income requirements differ based on your needs. These are the 2018 requirements for senior groups (subject to change every year):

MEDICALLY NEEDY

If your monthly income and assets are at or below the following limits either before or after health expenses, you may qualify:

• Family of 1 – $241 income, $2,000 assets
• Family of 2 – $258 income, $3,000 assets
• Family of 3 – $317 income
• Family of 4 – $325 income

SUPPLEMENTAL SECURITY INCOME (SSI)

Those who are disabled and receive social security supplemental income qualify with the following monthly income and asset limits:

• Family of 1 – $750 income, $2,000 assets
• Family of 2 – $1,125 income, $3,000 assets

INSTITUTIONALIZED INDIVIDUALS

If you require nursing facility care or if you receive home and community-based services, you may qualify with the following monthly income and asset limits:

• $2,205 income, $2,000 assets

WOMEN WITH BREAST OR CERVICAL CANCER

Women who have been screened through an approved Breast and Cervical Cancer Early Detection Program (BCCP) and require treatment can receive TennCare coverage if financially necessary. To qualify, you cannot have Medicare or another form of insurance that covers breast and cervical cancer treatment and you must be below 250% of the federal poverty level.

Medicare Cost Sharing Programs

If you are eligible for Medicaid and are over the age of 65, you are eligible for Medicare as well! Those who are eligible for both are considered dual-eligible and can qualify for Medicare Cost Sharing programs like:

QUALIFYING INDIVIDUALS (QI 1)

You can qualify for QI 1 if you fall between 120% and 135% of the federal poverty level and if your yearly income is:

• Family of 1 – $14,568 – $16,389
• Family of 2 – $19,752 – $22,221

QUALIFIED DISABLED WORKING INDIVIDUALS (QDWI)

You can qualify for this if you are disabled, employed, at 200% or less of the Federal Poverty Limit, and fall under the following limits:

• Family of 1 – Income limit of $24,280 and have asset limit of $4,000
• Family of 2 – Income limit of $32,920 and asset limit of $6,000

QUALIFIED MEDICARE BENEFICIARIES (QMB)

You can qualify for QMB if you are at 100% or less of the Federal Poverty Level and meet the following limitations:

• Family of 1 – Income limit of $1,012 and asset limit of $7,560
• Family of 2 – Income limit of $1,372 and asset limit of $11,340

SPECIFIED LOW INCOME MEDICARE BENEFICIARIES (SLMB)

You may qualify for SLMB if you are between 100% and 120% of the Federal Poverty Level and you meet the following limits:

• Family of 1 – Income limit of $12,140-$12,568 and asset limit of $7,560
• Family of 2 – Income limit of $16,460-$19,752 and asset limit of $11,340

How Much Does Medicare Cost in Tennessee?

Eligible beneficiaries in Tennessee receive coverage through Medicare Part A at no cost if they have met eligibility requirements.  If you don’t meet requirements, then you will need to buy Part A at a cost of $422 per month if you paid Medicare taxes for less than 30 quarters. If you paid Medicare taxes for 30-39 quarters, then the standard premium will be $232.

The standard Part B premium amount is $134 but could be higher depending on a beneficiaries’ income.  Part B deductible and coinsurance is $183 per year. After a deductible is met, you typically pay 20% of the Medicare-approved amount for most doctor services (including most doctor services while you’re a hospital inpatient), outpatient therapy, and durable medical equipment.

Medicare Part C, also known as Medicare Advantage, offers a different way to receive Medicare Part A and Part B benefits.  Private Medicare providers cover required services and oftentimes offer enhanced coverage in exchange for a beneficiary paying a premium for the added coverage.

Part D coverage pays for prescription drugs and is also offered by Tennessee Medicare-approved insurance providers at an additional premium.

Part C and Part D coverage will vary by location and provider and will also be based in part on the level of coverage.  Higher income consumers may pay more in premiums as well.

For more details on Medicare costs for 2018, go here.

Cost and Coverage of Medicaid Tennessee

TennCare insurance does not require a premium as long as you meet the income guidelines. You may have copayments for some services. If you have any other insurance, like Medicare or a private insurance plan, your other plans will pay before Medicaid. Medicaid can cover whatever your other plans didn’t cover, but your other plans must pay first.

Prescription Drugs with Medicaid Tennessee

TennCare allows five prescriptions per month for most enrollees. Enrollees receiving nursing home care or other long-term care with TennCare may be allowed more. There is also an “Automatic Exemption List” of over 600 medications that do not count towards limits.

Which Medicare Plan is Best in Tennessee?

There is no easy answer to this question because everyone’s needs and situations are different.  While there are standardized Medicare supplement plans, the prices are almost always different.

The way to determine which Medicare plan is best in Tennessee is to shop your options. By fully shopping your options you’ll be able to find the best plan that fits you.  Below are some considerations for finding which Medicare plan is best in Tennessee.

• Use the Part D plan finder to enter your drugs to identify the tiers and associated copays.
• If maintaining your current provider is important to you, compare the networks of primary doctors and specialists to ensure your doctor is in network
• Understand the additional benefits you may qualify for such as dental, vision, hearing, and wellness.
• Fully research other factors that are important to your current situation and then factor the results into your final decision

Once you have gone through these exercises in full, you’ll be better suited to determine which Medicare plan is best in Tennessee for you.

Which Medicaid Plan Would be Best in Tennessee?

There are two kinds of TennCare Medicaid coverage.

TennCare Medicaid

TennCare is the state of Tennessee’s Medicaid program. It provides healthcare to mostly low-income pregnant women, parents or caretakers of a minor child, children and individuals who are elderly or have a disability.  To get Medicaid, you must meet the income and resource limits. You can apply anytime for TennCare.

There are several different groups of people that may qualify. Each group has different income limits. Some of the groups also have limits on how much you own, known as your “resources.” These are things like bank accounts, cars, and land. The number of people who live in your household count too.

Some of the groups TennCare Medicaid covers are:

• Children under age 21
• Women who are pregnant
• Parents or caretakers of a minor child (The child must live with you and be a close relative.)
• Women who need treatment for breast or cervical cancer
• People who get an SSI check (Supplemental Security Income)
• People who have gotten both an SSI check and a Social Security check in the same month at least once since April 1977 AND who still get a Social Security check
• A person who:
  • Lives in a nursing home and has income below $2,205 per month, or
  • Gets other long-term care services that TennCare pays for

TennCare Standard

TennCare Standard is only available for children under age 19 who are already enrolled in TennCare Medicaid and:

• Who lack access to group health insurance through their parents’ employer, or
• Their time of eligibility is ending, and they don’t qualify anymore for TennCare Medicaid.

Dual Eligibile Medicare and Medicaid Plans in Tennessee

If you are dual eligible, you can be covered by both Medicare and Medicaid at the same time. That means you also qualify for Medicare Part A, Medicare Part B, and a Medicare Savings program that can help you pay for Medicare deductibles, coinsurance, and copayments.  

The four kinds of Medicare Savings Programs are the Qualified Medicare Beneficiary Program, the Specified Low-Income Medicare Beneficiary Program, the Qualifying Individual Program and the Qualified Disabled and Working Individuals Program.  A Medicare Plan Finder agent can help you figure out what you qualify for.

How to get TennCare Coverage

The first step in getting TennCare Coverage is calling your health plan. You can find the number on your TennCare card. If you still have problems after speaking with your TennCare provider, or if you cannot find your card, call the TennCare Solutions number at 1-800-878-3192.

If TennCare stops or changes your health care, you have to wait too long, or TennCare does not pay for something that should’ve been covered, you have 30 days to file an appeal. Once you file your appeal, you will hear a decision within 90 days. If you are in an emergency situation (such as if you need emergency healthcare or need to be hospitalized and cannot afford it) and cannot wait 90 days, ask TennCare for an emergency appeal. Ask your doctor to sign off on your appeal and label it as an emergency situation.

If you feel that TennCare is treating you differently based on your race, birthplace, religion, language, sex, age, or disability, call Tennessee Health Connection at 1-855-259-0701.

For More Information About TennCare

If you need any help with TennCare insurance, call the Tennessee Health Connection. Their number is 1-855-259-0701.  You can use this number to apply for TennCare, report changes, ask questions or file an appeal to either get or keep TennCare.  The phone number is staffed Monday through Saturday from 7 am to 7 pm.

Do you use a TTY or TDD machine? If so, call 1-877-779-3103.

For questions and assistance with your health care plan or if you have TennCare issues, call the TennCare Advocacy Program at 1-800-758-1638.  You can also call the TennCare phone number (Solutions Unit) at 1-800-878-3192.

If you have questions about Medicare for people over age 65 or disabled call Tennessee’s State Health Insurance Assistance Program (SHIP). Their number is 1-877-801-0044.

You can send email inquiries to Tenn.Care@tn.gov.

Answers can also be found on the TennCare website located here.