Getting Coverage for Kids

There are 62,000 uninsured children in Tennessee. That is too many. In fact, Kids Count reports that Tennessee ranks 38th nationally in child well-being and that 26% of Tennessee children live in poverty. Almost every child is eligible for some form of health insurance: whether it’s TennCare, CoverKids, affordable private plans on www.healthcare.gov, or employer-sponsored insurance through a parent.

Children with insurance are more likely to receive preventive care, perform better in school, graduate from high school, and be successful as adults. This page explores the different health insurance options for children; advises on how to enroll in these programs; and helps insured children access medically-necessary medical services.

Have you had any problems with TennCare? If so, you can file an appeal.

What is an appeal?

  • An appeal is a way to fix a TennCare mistake.
  • An appeal can get TennCare to say yes.

You can appeal if:

  • TennCare won’t pay for care, OR
  • TennCare stops or changes your care, OR
  • TennCare Oks less care than your doctor ordered, OR
  • You have to wait to get care, OR
  • You can’t find a doctor to see your child.

How do you appeal?

First: Fill out a TennCare Medical Appeal form online: http://www.tn.gov/tenncare/forms/medappeal.pdf

How do you send the appeal? There are 3 different ways.

  1. Mail the form to TennCare. Save a copy of your form.

TennCare Solutions

PO Box 593

Nashville, TN 37202-0593

  1. Fax the form to 1-888-345-5575.
  • Keep the paper that shows the fax was sent.
  1. Call 1-800-878-3192 for any QUESTIONS.

Eligibility Delay Appeal

Have you waited for a decision for more than 45 days (or more than 90 days for long-term care) on your application for Medicaid?
You can now ask for a delay hearing.
For more information click here.

How do you ask for a delay hearing?

There are 2 different ways.

1. Fill out a TennCare Eligibility Appeal form online:
www.tn.gov/tenncare/forms/RequestWilsonHearingForm.pdf
– The form tells you how to send by mail or fax.

2. Call 1-800-259-0701.

What does TennCare Cover?

TennCare must follow a law called EPSDT, which stands for “Early and Periodic Screening, Diagnosis and Treatment.”

What does it mean?

EPSDT means that you don’t have to take no for an answer!

What does this mean for kids on TennCare?

  • EPSDT says that kids on TennCare should have all medically necessary care.
  • This includes care for physical health, mental health, and medicine.

What if TennCare says your child’s care is not covered? Call TJC!

Kids on TennCare should have all medically necessary care.

What is it?

  • “Medically necessary” are the magic words that make TennCare pay for a child’s care.
  • If you are on TennCare and under 21, TennCare will pay for ANY medical services that are medically necessary.

What does that mean for your child?

TennCare only pays for care:

  • Ordered by a doctor, and
  • Needed to find out what’s wrong or to treat it, and
  • Safe and it works, and
  • Not an experiment (effective), and
  • The cheapest care that is enough (adequate).

Services TennCare Covers

  • Doctor’s Visits
  • Wheelchairs
  • Shots
  • Eye Glasses
  • Medicine
  • Surgery

Do you have newborn? Look here to find out how you can help them get coverage right away: 11-6-14 Newborn Cheat Sheet

Resources and helpful links:

Georgetown University Health Policy Institute Center for Children and Families – Fact Sheet: Medicaid’s Role for Children
Georgetown University Health Policy Institute Center for Children and Families report

Kids Count Data Center Tennessee Indicators

Tennessee State Government news release (June 21, 2016)

See how TJC helped children like Timmy and Darius get the coverage they needed!