Section 1240-03-02-.03 - COVERAGE OF THE MEDICALLY NEEDYThe following groups of medically needy individuals, if otherwise eligible, are covered:
(1) Pregnant women in one or two-parent families who, but for income and resources, would be eligible as Categorically Needy (Families First/AFDC) and who meet the Medically Needy financial requirements shall remain eligible without regard to income changes and for two (2) full calendar months of postpartum coverage regardless of changes in circumstances.(2) Aged, blind and disabled non-pregnant individuals age twenty-one (21) and older are no longer eligible for coverage as Medically Needy. Effective April 30, 2005 enrollment in the Medically Needy Category was closed to new enrollees except for children under age twenty-one (21) and pregnant women. Currently eligible Medically Needy Adults will be given the opportunity to apply for Standard Spend Down. Individuals who are subsequently approved will be given coverage for a period of twelve (12) months from their begin date.(a) Prior to actual enrollment in Standard Spend Down, the Transition Group enrollees were looked at for eligibility in an open category of Medicaid through the ex parte review process. Transition Group enrollees not found eligible in an open category of Medicaid, will be selected for Standard Spend Down processing through the Request for Information (RFI) process.(3) Children under age twenty-one (21), Caretaker.(a) All children under age twenty-one (21) who meet the Medically Needy technical and financial eligibility requirements. The caretaker of such children is also covered if: 1. The caretaker is pregnant; or2. The caretaker is under age twenty-one (21).(b) Both parents of a dependent child, if both parents are under age twenty-one (21) may be covered, if otherwise eligible.(c) Newborns of women in one or two-parent families are covered effective from date of birth and continue as long as the child is living with the mother and the mother is Medicaid eligible or if she would be Medicaid eligible, if she were pregnant, up to one (1) year.(4) Pregnant women and children under twenty-one (21) are classified as Exceptional Medically Needy or Spenddown Medically Needy. Persons are exceptional Medically Needy if eligibility is due to their regular monthly income being equal to or below the medically needy eligibility standards.(5) Whenever a pregnant woman or child under twenty-one (21) has income which prevents their qualifying as Exceptional Medically Needy eligibility on the basis of income, spenddown eligibility is determined pursuant to these rules.(6) Individuals who meet Standard Spend Down (SSD) criteria:(a) Tennessee residents who have been determined to be eligible for the Standard Spend Down (SSD) program.(b) Individuals enrolled must meet the following criteria:1. Must be aged twenty-one (21) or older;2. Must not be pregnant; or3. Must meet one of the following criteria:(i) Be sixty-five (65) years of age or older, or(ii) Be blind, as defined in rule 1240-03-03-.02(3); or(iii) Be disabled, as defined in rule 1240-03-03-.02(4); or(iv) Be a "caretaker relative" of a Medicaid-eligible dependent child as defined in T.C.A. § 71-3-153; and4. Must meet the financial eligibility criteria for income and resources that apply to Medically Needy pregnant women and children eligible under the State plan. These criteria are found at rules 1240-03-03-.05 and 1240-03-03-.06.Tenn. Comp. R. & Regs. 1240-03-02-.03
Original rule filed June 14, 1976; effective July 14, 1976. Amendment filed September 15, 1977; effective October 14, 1977. Amendment filed June 9, 1981; effective October 15, 1981. Repeal and new rule filed August 17, 1982; effective September 16, 1982. Amendment filed January 7, 1985; effective February 6, 1985. Amendment filed February 26, 1985; effective March 28, 1985. Amendment filed September 19, 1985; effective December 14, 1985. Amendment filed May 23, 1986; effective August 12, 1986. Amendment filed May 23, 1988; effective August 29, 1988. Amendment filed August 9, 1989; effective September 23, 1989. Amendment filed January 31, 1990; effective March 17, 1990. Amendment filed August 17, 1992; effective October 8, 1992. Amendment filed December 30, 1993; effective March 15, 1994. Amendment filed April 23, 1997; effective July 7, 1997. Amendment filed October 26, 2001; effective January 9, 2002. Repeal and new rule filed April 22, 2008; effective July 6, 2008.Authority: T.C.A. §§ 4-5-201 et seq., 4-5-202, 71-1-105(12), 71-5-102, 71-5-106 and 71-5-109; 42 U.S.C.§ 1315. and 42 USC §1396 et seq., 42 USC §1396a(a)(10)(A)(ii); PL 100-485§401; 42 USC §1396a(e)(4) and (1)(1); and 42 CFR § 435.831, 42 C.F.R. § 435.210 and 42 C.F.R. § 435.201; and TennCare II Medicaid Section 1115 Demonstration Waiver.