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Administrative Manual Policy Manual Number: 200.040 Section: General Administrative Procedures and Compliance Chapter: Eligibility Determination

June 2, 2025 Division of TennCare 3

documents are reviewed.

7. Notice of Determination

Notice of eligibility determinations are sent to individuals promptly after an eligibility determination is finalized. Once an eligibility determination is finalized, a notice of the eligibility determination is sent to the individual or her responsible party. The notice includes the following:

a. The decision regarding the individual’s eligibility; b. If eligibility is denied, the specific reason for denial and citations of specific regulations that support the denial; c. A statement to inform the individual of his right to appeal the eligibility determination. The notice will provide additional information about how to file an appeal; and d. A reminder to report any household changes within 10 days of the date the notice is received.

8. Eligibility Effective Date

The TennCare III Medicaid Section 1115 Demonstration waiver enables TennCare to waive the eligibility begin date requirement under the Social Security Act § 1902(a)(34) and 42 CFR 435.915 for all applicants except for pregnant women (as defined in the Pregnancy MAGI policy), and children under age 19 described in Section 1902(l)(4) of the Social Security Act. For applicants who do not meet the criteria to be considered for retroactive eligibility, eligibility is not extended to a date prior to the date an application is received.

Pregnant women (as defined in the Pregnancy MAGI policy), and children under age 19 described in Section 1902(l)(4) of the Social Security Act, who attest to receiving a service covered under the Medicaid state plan during the three months prior to the month of application (referred to as the retroactive eligibility period), will be tested for eligibility during the retroactive eligibility period. Eligibility could begin as early as the first day of the third month prior to the month of application if the individual meets all eligibility requirements.

Note: Pregnant women and children are potentially eligible for retroactive eligibility in one of the following categories: Child MAGI 0-1, Child MAGI 1-5, Child MAGI 6-18, Pregnancy MAGI, and Caretaker Relative. To qualify for retroactive coverage in the Caretaker Relative category, the individual must be pregnant. A pregnant woman or child under the age of 19 and grouping for Emergency Medical Services on the basis of a mandatory Category of Eligibility (COE) (i.e., Child MAGI, Pregnancy MAGI or Caretaker Relative) is also eligible to be tested for coverage during the retroactive eligibility period.