TENNCARE ENROLLMENT AND APPEAL HELP
If you are looking for help with TennCare enrollment or an appeal, the Tennessee Justice Center provides free legal assistance to Tennesseans across the state. Our trained staff help families cut through red tape to get vital health care and nutrition benefits. TJC can help with these types of problems:
- TennCare questions
- TennCare enrollment or redetermination problems
- Delayed TennCare enrollment application
- TennCare won’t cover care you need / that your doctor ordered
- Problems with Medicare Savings Programs
- Help see if you are eligible for insurance coverage or find other health care resources
- Problems with long-term care programs like TennCare CHOICES or ECF CHOICES
- SNAP (food stamps) questions or problems
Call us toll-free at 877-608-1009 to find out more about TennCare enrollment and appeals. All our help is free.
TJC is not able to help with other types of problems like SSI / SSDI applications or questions, medical malpractice, or criminal matters.
WHAT IS TENNCARE?
Every state has a Medicaid program. In Tennessee, it’s called TennCare. TennCare provides health insurance to low-income individuals including pregnant women, children, adults with minor children and people with disabilities. In addition, TennCare also pays for the nursing home level of care for adults who qualify medically and financially. This can be provided in your home or in a nursing home. TennCare enrollment and appeals can be tricky, please call our office if you’re having difficulties getting coverage.
When mailing TennCare make sure you:
- Make copies of all documents being sent to TennCare. There is no guarantee your documents will be returned to you;
- Send certified mail, return receipt requested. Save copies of these documents from the post office.
The most preferred method of providing documents to TennCare is by fax. When faxing TennCare make sure you:
- Do NOT include a cover page with your fax;
- Save the fax receipt along with a copy of the faxed documents.
If you call TennCare including the call center known as “Tennessee Health Connections”, please take notes about the following:
- Date and time of call;
- Pate and time of call;
- The representative’s name;
- Make sure they have your current address;
- The information that you were provided;
- Any deadlines;
If you have TennCare and received a medical bill that was not paid in full, you have a right to appeal. In addition, you may be able to stop the debt collectors from calling about your medical bill. If you want us to check to see if you have a legal reason for your appeal or help to file it, please give us a call 1-877-608-1009
Some people find out they lost their TennCare when they go to a doctor or try and fill a prescription for medication. Call Tennessee Health Connections at 1-855-259-0701 (toll FREE) and ask when your TennCare was terminated and why. If you do not think this is correct, please give us a call 1-877-608-1009
There can be a variety of reasons why your TennCare is being terminated. The letter you received from TennCare should tell you why. If you do not think this is correct, you have the right to appeal. It is important that you appeal as soon as possible and ask for “Continuation of Benefits”. Continuation of benefits means you can keep your TennCare until a decision is made regarding your appeal. Please note all deadlines contained in the letter from TennCare. If you want us to check to see if you have a legal reason for your appeal or help to file it, please give us a call 1-877-608-1009
Nothing can be more frustrating or dangerous than a missed nursing shift. It is important that you make a note every time this happens. In the note include the date and time of the missed shift, the agency name responsible for the shift, and any other information about the missed shift. For example, whether you were told ahead of time the shift would be missed, bad weather, etc. Every missed shift is grounds for an appeal. If you need help filing an appeal for missed nursing shifts, please give us a call 1-877-608-1009
You have the right to appeal TennCare’s decision to deny a medical service or medication prescribed by a doctor. If you want us to check to see if you have a legal reason for your appeal or help to file it, please give us a call 1-877-608-1009
This packet is referred by TennCare as a “Renewal Packet”. The purpose of the renewal packet is to see if you still qualify for TennCare, CHOICES or Medicare Savings Program. This process is called “Redetermination”. The renewal packets are large and can be difficult to complete. WARNING: if you do not complete and return the packet by the deadline, your TennCare will be terminated. If you need help completing the renewal packet, please call us 1-877-608-1009
If the date you applied for TennCare does not match the effective date of coverage, there may be a problem. Please give us a call: 1-877-608-1009
If you denied TennCare, and believe the decision is wrong. You have a right to appeal. Please be aware there are time limits for filing an appeal. If you want us to check to see if you have a legal reason for your appeal or help filing it, please give us a call.
It can take a while to receive an answer from TennCare. For most categories of TennCare, it can take up to 45 days to find out if you are eligible and up to 90 days if you have applied for CHOICES. Once approved, your coverage start date will most likely be the date of your application.
It is important to watch your mail for a letter from TennCare asking for more information about your application. TennCare usually asks for proof of your income or your citizenship status. Please pay attention to any deadlines contained in the letter.
If more than 45 days (or 90 days for CHOICES) has passed since you applied, you must file an appeal. For help filing an appeal, please call us 1-877-608-1009.
WHAT IS THE CHOICES PROGRAM?
CHOICES is Tennessee’s long-term care program. CHOICES might help you or your loved one get long-term care. CHOICES can help you get the home care you need to stay in the community. It might also pay for care in a nursing home.
ECF CHOICES is for individuals of all ages and individuals with significant disabilities. Because of limited funding, not everyone who applies or enrolls receive services right away. However, those who qualify for one of TennCare’s designated priority categories may get services right away. TennCare lists all the priority categories here, but they include individuals with emergent needs or multiple complex health conditions, individuals who are employed, seeking employment, or desire to be employed, and individuals with aging caregivers 75 or older.
TENNCARE ENROLLMENT AND APPEALS: COMMON QUESTIONS
Getting a safety determination can be hard. Please call Tennessee Justice Center for free help at 877-608-1009.
Here are some general tips for getting a safety determination:
- It is best to ask for a Safety Determination any time you do a PAE. This way TennCare is more likely to get the best picture of what your needs really are. The person who did your PAE should know how to add the safety to your PAE.
- Or, you can call the TennCare Division of Long-Term Supports and Services and ask for a safety determination. Their phone number is 877-224-0219.
- You can write a letter to include in the safety that tells the State why you don’t think you will be safe at home. You can have your doctors, relatives, or others write about why you need help in a nursing home or why you need a higher level of care at home. They can say why limited help at home will not be enough for you.
- Fax any documents about your case to the TennCare Division of Long-Term Services and Supports. Their fax number is 615-734-5411. Write your name, Social Security Number, and date of birth on your fax cover page. If you have it, also write your PAE control number.
Remember: If you are not safe at home with CHOICES 3, you may be able to get help in a nursing home. Ask for a safety determination, and it could be a way for you to get approved for either CHOICES Group 1 (care at a nursing home) or Group 2 (same level of care at home).
A safety determination (sometimes called a “safety” for short) is a test that can be done with a PAE to give a better picture of the care you need. If you didn’t score a 9 on the PAE, and/or you need a higher level of care that you were approved for, you may be able to get help with a safety determination.
If the safety determination says you cannot be safe in your home, you may be able to get the care you need.
TennCare does not automatically do a safety. You have to ask for it. You should always ask for a safety. If you have a history of falls, had a big change in health, had a big change with your caregiver, or have been hospitalized, tell the person who did your PAE these things when you ask for a safety determination.
Tennessee Justice Center helps some people with ECF CHOICES issues. Call our office at 877-608-1009. Even if we cannot represent you in the hearing, we can help talk through the situation, take a look at documents, and see what options you have. If your application was denied or you are experiencing service issues, an appeal may help.
You may be able to get a free lawyer to help at your hearing. Call your local legal aid office. You can find the phone number for your local legal aid office here.
You can go to your hearing yourself if you can’t get a lawyer. You can win your hearing even without a lawyer. You can take a friend or advocate with you. Tell the judge about why you need ECF CHOICES and what mistake you think TennCare made.
ECF CHOICES eligibility is complicated. Feel free to call Tennessee Justice Center for free help at 877-608-1009.
To apply, you will need to fill out TennCare’s self-referral form online.
This form must be filled out by anyone seeking services through the program.
Important note: If you are currently receiving services through a DIDD waiver program, you are not required to switch over to the ECF CHOICES program. This is your choice. However, if you choose to switch from a DIDD waiver program to ECF CHOICES you will not be able to switch back. The DIDD waivers are closed to new enrollment.
If you have questions or need assistance completing the self-referral form:
If you are already on TennCare, contact your MCO. BlueCare (888-747-8955), Amerigroup (866-840-4991) and United Healthcare (800-690-1606) all participate in ECF CHOICES.
If you are not on TennCare, contact DIDD. DIDD Regional Intake Office Contact information:
West Tennessee Regional Office Office of Intake (866) 372-5709
Middle Tennessee Regional Office Office of Intake (800) 654-4839
East Tennessee Regional Office Office of Intake (888) 531-9876
ECF CHOICES aims to serve the following people:
- Individuals with emergent needs or multiple complex health conditions
- Individuals who are employed, seeking employment or desired to be employed
Individuals with aging caregivers 75 years or older
If an individual is determined by TennCare to be in one of these priority categories, they must also meet a certain level of care criteria to be eligible for services. An individual must either meet nursing facility level of care or be at-risk of needing nursing facility level of care. An individual must also be evaluated based on an ICAP (Inventory for Client and Agency Planning). The level of care criteria is
- Meet nursing facility level of care
- Be “at risk” of nursing facility treatment
- Intellectual disability: limitations in 2 or more adaptive skill areas
- Developmental disability: substantial functional limitations in 3 or more major life activities
If an individual meets this level of care, they must also be financially eligible for ECF CHOICES. Their income must be below $2,250 and they must have resources valued at less than $2,000. Note: The parents’ income counts for an applicant only if the child’s level of need is determined to be “at-risk” and not at nursing facility level of care.
Tennessee Justice Center will provide free assistance with ECF CHOICES. Call us at 1-877-608-1009.
ECF CHOICES is for individuals of all ages and individuals with significant disabilities. Because of limited funding, not everyone who applies or enrolls receive services right away. However, those who qualify for one of TennCare’s designated priority categories may get services right away. TennCare lists all the priority categories here, but they include individuals with emergent needs or multiple complex health conditions, individuals who are employed, seeking employment, or desire to be employed, and individuals with aging caregivers 75 or older. See the image below for examples of people who may qualify:
- Individuals with emergent needs or multiple complex health conditions
- Individuals who are employed, seeking employment or desired to be employed
- Individuals with aging caregivers 75 years or older
- If an individual is determined by TennCare to be in one of these priority categories, they must also meet certain level of care criteria to be eligible for services. An individual must either meet nursing facility level of care, or be at-risk of needing nursing facility level of care. An individual must also be evaluated based on an ICAP (Inventory for Client and Agency Planning). The level of care criteria is
Call the Tennessee Justice Center for free help at 1-877-608-1009.
TennCare should send a letter that says you can’t get CHOICES. The letter should tell you how to appeal. An appeal tells the State that you think they made a mistake. The State will look at your case again when you appeal.
Sometimes, this fixes your problem. If not, you may get a hearing. At the hearing, you will get to tell a judge why you think TennCare made a mistake.
There are two types of appeals:
Medical or PAE appeal
What if the State says you cannot get CHOICES because you don’t meet the medical rules?
You can use this appeal form. You can also write a letter about your problem. If possible, you should use a fax machine to send your appeal. Save the page showing when you faxed it. If you can’t send a fax, you can send it by mail.
You can also file an appeal by phone. Call TennCare Division of Long-Term Services and Supports. Their phone number is 877-224-0219. Write down the time and date you called and the name of the person you talked to.
What if the State says you cannot get CHOICES because your income is too high or there is a problem with your assets?
You can use this appeal form. (This is a different appeal form than what you use for a PAE appeal!) If possible, you should fax the appeal form. Save the page showing when you faxed it. If you can’t send a fax, you can send it by mail.
You can also file a financial appeal by phone. Call Tennessee Health Connection. Their phone number is 855-259-0701. Write down the time and date you called and the name of the person you talked to.
There are 2 parts to getting help through the CHOICES program.
Medical Need for CHOICES
To get CHOICES, your medical needs must be so serious that you need help with your daily tasks. These are called “activities of daily living” or ADLs.
If you need help with any of these, you might be able to get CHOICES.
- Transfer – You need help moving from your bed to your bed, chair, or toilet.
- Mobility – You need help with walking.
- Eating – You need help or constant one-on-one observation and verbal assistance to put food in your mouth, chew, or swallow safely.
- Toileting – You need help adjusting your clothes to toilet, cleaning yourself , changing your own diaper, or cleaning up toileting accidents
- Expressive / Receptive Communication – You need help telling others about your needs and wants (like you’re hungry or are in pain). OR you need help following simple directions
- Orientation – You need help knowing and remembering people (like your family members) and where you are.
Medication Administration – You need help taking, injecting, or applying your medicine.
- Behavior – You have behavior problems which cause you or others to be at risk for serious harm.Need for
- Skilled Nursing or Rehabilitative Services – TennCare also looks at your need for some types of health care from a nurse. Needing this care could also help you get CHOICES.
- Need for Skilled Nursing or Rehabilitative Services – You need some types of health care from a nurse. You might be able to get CHOICES if you need help with daily tasks. TennCare will give you a score on their “acuity scale.” Acuity means how bad your health problems are. You can get more information about the medical rules for CHOICES from this flier from Legal Aid Society of Middle Tennessee and the Cumberlands.
Here is a short flier that tells you exactly how the State defines these problems. You might want to show this paper to your doctor.
You have the right to appeal if TennCare says you can’t get CHOICES. You also have the right to appeal if TennCare says you can only get CHOICES 3, but you need more care than what CHOICES 3 will pay for.
Financial Need for CHOICES
To get CHOICES, you also need to show that you have income and resources that are low enough. You will fill out a paper that asks you about what money you get each month. The paper also asks about money that you have in the bank. It also asks about other things you own that are worth money, like your house or car. Only the applicant’s income counts, and only the applicant’s share of the resources.
The 2018 income limit is $2,250/month. The resource limit (excluding a house and a car) is $2,000.
The rules for the financial need for CHOICES are confusing. If you are told you can’t get CHOICES because you make too much money, you may still be able to get CHOICES. You may be able to set up a Qualified Income Trust (QIT), also called a Miller Trust. Tennessee Justice Center can help you set up a QIT.
If you are told you cannot get CHOICES for financial reasons, but you think that TennCare has made a mistake, you can appeal.
You can get more information about the financial rules for CHOICES from this flier from Legal Aid.
CHOICES is Tennessee’s long-term care program. CHOICES might help you or your loved one get long-term care. CHOICES can help you get the home care you need to stay in the community. It might also pay for care in a nursing home. CHOICES eligibility is complicated. Feel free to call Tennessee Justice Center for free help at 877-608-1009.
There are three different groups of CHOICES.
- CHOICES Group 1 – Nursing home care for people of any age.
- CHOICES Group 2 – Home services that don’t cost more than a nursing home. You must be older than 65 OR older than 21 with a physical disability.
- CHOICES Group 3 – Home services that cost no more than $15,000 per year. You must be older than 65 OR older than 21 with a physical disability. As of July 1, 2015, you must be getting Supplemental Security Income (SSI) to get CHOICES 3.
QUESTIONS ABOUT OTHER BENEFITS
Supplemental Nutrition Assistance Program (SNAP)
SNAP is our nation’s largest effort to directly address hunger and is built on a very successful public-private partnership with food retailers and farmers. Over one million of our neighbors, or almost one in six Tennesseans, use SNAP to help make ends meet. About four out of every five participants in Tennessee are children, older adults, and adults with disabilities.
If you or a loved one has a question about SNAP or is food insecure please call the Tennessee Justice Center for assistance: 1-877-608-1009
Medicare Savings Programs (MSP)
You might be able to get help from your state paying your Medicare premiums. Medicare Savings Programs may also pay Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) deductibles, coinsurance, and copayments.
There Are 4 Kinds of MSPs
- Qualified Medicare Beneficiary (QMB) Program
- Low-Income Medicare Beneficiary (SLMB) Program
- Qualifying Individual (QI) Program
- Qualified Disabled and Working Individuals (QDWI) Program
Call the Tennessee Justice Center.
We will provide free assistance with an MSP application, redetermination or appeal 1-877-608-1009.
In recent months, TJC has received a flood of calls from older Tennesseans who have discovered that their Medicare Savings Program (MSP) benefits have been terminated by TennCare.
Many individuals who have had their MSP benefits terminated report that they never received a renewal packet or a termination notice from TennCare. They only discover that their MSP benefits have been terminated when they receive a notice from Social Security saying that TennCare will no longer pay for their Medicare premiums and that these premiums now will be taken out of their monthly Social Security check.
If you, or someone you know, have this problem please contact our office: 877-608-1009.
Call the Tennessee Justice Center.
We will walk you through the renewal process 1-877-608-1009
Medicare Part D Low Income Subsidy (Extra Help) helps some people pay for their medicine expenses on Medicare. You can find out more here. You can also call the State Health Insurance Assistance Program (SHIP). SHIP is a free call-in line for Medicare questions. Their phone number is 1-877-801-0044.
The Low Income Home Energy Assistance Program (LIHEAP) helps low income older adults and individuals with disabilities with their home energy costs. LIHEAP is 100 percent federally funded through a grant from the Federal Department of Health and Human Services.
Eligible applicants can receive assistance once per year from two of the three programs. You can find out more by contacting the LIHEAP program in your area.