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Eligibility Categories

Major Medicaid Eligibility Categories in Tennessee

This provides a short description of some of the Medicaid programs available in Tennessee. This information should be used as reference only. To see if you may qualify for Medicaid or complete an application on line, please visit https://www.healthcare.gov/. Or call 1-800-318-2596.

Click on a category, below, for more information.

The categories listed below are cost sharing assistance programs for people with low income who have Medicare. This is not TennCare Medicaid. You must apply for TennCare Medicaid separately.



Children

Brief Description
Low income children ages 0 to 19.

Annual (yearly) Income Limit

Age 0 to 1 – 195% FPL
$22,757 (family size of 1)
$30,674 (family size of 2)
$38,591 (family size of 3)
$46,508 (family size of 4)

Ages  1 to 6 – 142% FPL
$16,572 (family size of 1)
$22,337 (family size of 2)
$28,102 (family size of 3)
$33,867 (family size of 4)

Ages 6 to 19 - 133% FPL
$15,522 (family size of 1)
$20,921 (family size of 2)
$26,321 (family size of 3)
$31,721 (family size of 4)

Comments
This is a mandatory program for states, although states can set the income standards. Eligibility is determined by the Health Insurance Marketplace.

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Pregnant Women

Brief Description
Low income pregnant women.

Annual (Yearly) Income Limit

195% FPL
$22,757 (family size of 1)
$30,674 (family size of 2)
$38,591 (family size of 3)
$46,508 (family size of 4)

Comments
This is a mandatory program for states, although states can set the income standards. Eligibility is determined by the Health Insurance Marketplace.

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Parents or Caretaker Relatives

Brief Description
Parents and other caretaker relatives of a minor child(ren)

Monthly Income Limit

$1,018 (family size of 1)
$1,329 (family size of 2)
$1,611 (family size of 3)
$1,867 (family size of 4)

Comments
This is a mandatory program for states, although states can set the income standards. Eligibility is determined by the Health Insurance Marketplace.

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Newborns

Brief Description
Children born to Medicaid eligible women.

Monthly Income Limit
None

Resource Limit
None

Comments
Newborns who are born to Medicaid eligible women are automatically eligible for one (1) year after birth. Then eligibility must be redetermined by TennCare.

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Medically Needy

Brief Description
Low income persons who are also one of the following:

  • Children up to age 21
  • Pregnant

Monthly Income Limit

Individual must either have income no more than the figures provided below OR have sufficient unreimbursed medical bills to "spend down" to these income limits, depending upon family size:

$241 (1)
$258 (2)
$317 (3)
$325 (4)

Resource Limit
$2,000 (1)
$3,000 (2)

Comments
This is an optional Medicaid category. Eligibility is determined by TennCare.
The "spend down" income level is set by the state.

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Supplemental Security Income (SSI)

Brief Description
Low income aged, blind, and/or disabled individuals.

Monthly Income Limit
$721 (1)
$1082 (2)

Resource Limit
$2,000 (1)
$3,000 (2)

Comments
This is a mandatory Medicaid eligibility category. Eligibility is determined by the Social Security Administration. Monthly cash assistance is provided by SSA.

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Institutionalized Individuals

Brief Description
Low income persons who require care in a nursing facility (NF) or intermediate care facility for the mentally retarded (ICF/IID) or who receive Home and Community-based Services (HCBS).

Monthly Income Limit
$2,163 (300% of the SSI benefit rate)

Resource Limit
$2,000

Comments
This is an optional Medicaid eligibility category. Need for placement in a NF, ICF/IID or HCBS is determined by the Bureau of TennCare or the Department of Intellectual and Developmental Disabilities. Financial eligibility is determined by TennCare.

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Women with Breast or Cervical Cancer

Brief Description
The Breast and Cervical Cancer Prevention (BCCP) category is an optional Medicaid category that covers women who have been screened through a Centers for Disease Control and Prevention ("CDC") approved Breast and Cervical Cancer Early Detection Program ("BCCP") and found to need treatment for breast and/or cervical cancer. In Tennessee the state program is operated by the Tennessee Department of Health (DOH), through the county health departments, and called the "TN Breast and Cervical Screening Program."

Tennessee women who are uninsured or whose insurance does not cover treatment for breast or cervical cancer, who are under age 65, and who have been determined by the County Health Department to need treatment for breast or cervical cancer are eligible to enrollee in TennCare Medicaid.

Monthly Income Limit
The screening guidelines required by the CDC Breast and Cervical Cancer Early Detection Program requires screened eligibles to be below 250 percent of the federal poverty level.

Resource Limit
None

Comments

HOW TO APPLY - Presumptive eligibility is an established period of time (45 days) during which certain women identified by the DOH as being uninsured and needing treatment for breast or cervical cancer-are eligible for Medicaid. During this period of time the presumptively eligible person must complete an application for Medicaid in order to stay on the program. All applicants must complete an application through the Health Insurance Marketplace at www.healthcare.gov.

Presumptive eligibility lasts for a period of 45 days. During the presumptive eligibility period, the enrollee must apply through the Health Insurance Marketplace to complete her enrollment in Medicaid. The applicant will be reviewed to determine if she is eligible for any other Medicaid category. If she is not eligible in another Medicaid category, she will be referred to TennCare.  We will determine if she is eligible in the BCC Medicaid category to cover her during the time she needs treatment for cervical or breast cancer. A redetermination of eligibility will occur at least every 12 months with TennCare and will be based on the need for continuing treatment for breast or cervical cancer, as determined by the woman's treating physician.

The effective date of eligibility is the date an application is approved at the Department of Health or at any alternative sites chosen by the Department of Health.

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TennCare Standard

Uninsured*

Brief Description
This category is only available to children under age 19 whose TennCare Medicaid eligibility is ending, who do not have access to insurance through a job or a family member's job, and whose family incomes are below 212% poverty. Eligibility is determined by TennCare.

Monthly Income Limit
211% poverty
$2,052 (family size of 1)
$2,766 (family size of 2)
$3,480 (family size of 3)
$4,194 (family size of 4)

Resource Limit
None

Comments
"Uninsured" means without access to insurance through one's job or a family member's job.  Coinsurance (co-pays) for some services is required for a TennCare Standard Uninsured child if the family income is at or above 100% poverty. For more information on co-pays go to http://www.tn.gov/tenncare/mem-copayments.shtml 

Medically Eligible*

Brief Description
This category is only available to children under age 19 whose TennCare Medicaid eligibility is ending and whose family income is greater than 211% of poverty. To be medically eligible, the child must have health conditions that make the child "uninsurable." The family is unable to purchase healthcare insurance for the child in the private market because of the child's health conditions. Eligibility is determined by TennCare.

Monthly Income Limit
Coinsurance (co-pays) for some services is required for a TennCare Standard Medically Eligible child if the family income is at or above 200% poverty.  For more information on co-pays go to http://www.tn.gov/tenncare/mem-copayments.shtml

Resource Limit
None

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Medicare Cost Sharing Programs


Qualifying Individuals (QI 1)

Brief Description
Cost sharing assistance for low income Medicare beneficiaries. You must meet criteria for one of the other Medicaid categories in order to get TennCare Medicaid.

Monthly Income Limit
Between 120% and 135% poverty
$1,167 - $1,313 (1)
$1,573 - $1,770(2)

Resource Limit
$7,160 (1)
$10,750 (2)

Comments
This is a mandatory Medicaid eligibility category. State is required to pay Medicare Part B premiums for these individuals as long as federal funds are available. They are not eligible for TennCare unless they meet the criteria for one of the other eligibility categories. Eligibility for this program is determined by TennCare.  To get an application, call the Tennessee Health Connection at 1-855-259-0701.

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Qualified Disabled Working Individuals (QDWI)

Brief Description
Low income disabled working individuals under age 65 who are entitled to Medicare Part A. You must meet criteria for one of the other Medicaid categories in order to get TennCare Medicaid.

Monthly Income Limit
200% poverty
$1,945 (1)
$2,622 (2)
$3,299 (3)

Resource Limit
$4,000 (1)
$6,000 (2)

Comments
This is a mandatory Medicaid eligibility category. State is required to pay Medicare Part A premiums for these individuals. They are not eligible for TennCare unless they meet the criteria for one of the other eligibility categories. Eligibility for this program is determined by TennCare.  To get an application, call the Tennessee Health Connection at 1-855-259-0701.

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Qualified Medicare Beneficiaries (QMB)

Brief Description
Low income persons eligible for Medicare Part A. You must meet criteria for one of the other Medicaid categories in order to get TennCare Medicaid.

Monthly Income Limit
100% poverty
$973 (1)
$1,311 (2)

Resource Limit
$7,160 (1)
$10,750 (2)

Comments
This is a mandatory Medicaid eligibility category. State is required to pay Medicare premiums, deductibles, and coinsurance for these individuals. They are not eligible for TennCare unless they meet the criteria for one of the other eligibility categories. Eligibility for this program is determined by TennCare.  To get an application, call the Tennessee Health Connection at 1-855-259-0701.

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Special Low Income Medicare Beneficiaries (SLMB)

Brief Description
Low income Medicare beneficiaries. You must meet criteria for one of the other Medicaid categories in order to get TennCare Medicaid.

Monthly Income Limit
Between 100% and 120% poverty
$973 - $1,167 (1)
$1,311 - $1,573 (2)

Resource Limit
$7,160 (1)
$10,750 (2)

Comments
This is a mandatory Medicaid eligibility category. State is required to pay Medicare Part B premiums for these individuals. They are not eligible for TennCare unless they meet the criteria for one of the other eligibility categories. Eligibility for this program is determined by TennCare.  To get an application, call the Tennessee Health Connection at 1-855-259-0701.

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