Page 14

pregnant woman or newborn falls within the CoverKids eligibility range, the signed application is submitted to the CoverKids TPA and presumptive eligibility is established. Presumptive eligibility begins on the date on which a qualified entity determines that a pregnant woman or newborn child is presumptively eligible and lasts until the TPA makes an eligibility determination. If any additional information necessary to make the eligibility determination is not submitted within 60 days of the start date, the application will be deactivated and presumptive eligibility will end. A pregnant woman or newborn may receive only one period of presumptive eligibility in an 18 month period.

Presumptive eligibility will also be provided for children transitioning from TennCare. This will allow children whose TennCare coverage is ending to have immediate coverage under CoverKids when TennCare coverage ends as long as all PE requirements are met. This type of presumptive eligibility will be performed by the CoverKids TPA. DHS will forward to the TPA a list of children who will lose TennCare coverage, including the date that coverage will end. The TPA will work with the family to obtain a signed CoverKids application. The period of presumptive eligibility will begin the day following the date that TennCare coverage ends, and end when the TPA makes a final determination of CoverKids eligibility or, if a completed application is not submitted, the last day of the month following the month in which the PE determination was made.

Renewal: Following approval of the CoverKids application, the child will be eligible for twelve months of continuous coverage regardless of changes in income. CoverKids eligibility may end prior to twelve months of coverage if the child is found ineligible at audit, turns age 19, or moves from the State. At the end of the twelve-month eligibility period, the family will be requested to update the eligibility information currently on file with CoverKids. Redetermination notices will be sent out 45 to 50 days prior to the end of the 12-month continuous eligibility period for CoverKids. This time period has been established so that there is sufficient time to identify children who are potentially eligible for TennCare and move them seamlessly to TennCare when eligible. The family will be asked to complete, sign and return the renewal form. Following return of the renewal form, eligibility will be reviewed and the family will be notified of the outcome. If the family income is now lower, they will also be sent information advising that the child appears to be Medicaid eligible and the TPA will assist the family in completing a Medicaid application. When a child is disenrolled from CoverKids, the vendor will also provide the family with a certificate of creditable coverage.

Eligibility Criteria: In order to be eligible for CoverKids, a child must meet the following criteria.

14