Tenncare Renewal Packet Details

Tenncare, the state’s health insurance program for residents who cannot afford other coverage options, is set to renew its membership packets starting in August. The Tenncare Renewal Packet 2017 Form will be sent to all enrollees eligible for renewal and must be completed and returned in order to maintain coverage. In this blog post, we will provide an overview of what you can expect from the renewal process as well as instructions on how to complete the packet. Be sure to check back for updates on the latest Tenncare news and information.

If you need to find out a number of specific details pertaining to the form you intend to use, here is the facts you may want to study before filling in the tenncare renewal packet 2017.

QuestionAnswer
Form NameTenncare Renewal Packet 2017
Form Length9 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 15 sec
Other namestenncare application printable, tc0131 form, printable application for tenncare, tenncare tc0131

Form Preview Example

Is someone helping you fill out these pages? You can choose an authorized representative.
Yes No
apply for TennCare go to www.healthcare.gov.
TN residents who need care in a nursing home.
TN residents age 65 and older or 21 and older with a physical disability who need services in their home and community to keep from going into a nursing home.
TN residents who have an intellectual or developmental disability and need services in the community. TN residents who have an intellectual disability and need care in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID).
TN residents who need hospice care in a nursing home.
TN residents who have Medicare and want to apply for help paying their Medicare cost sharing, like QMB, SLMB, QDWI, or QI1. If you qualify, TennCare pays your Medicare premiums and sometimes your Medicare co-pays, and deductibles.

LTSS and MSP APPLICATION.3

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TENNCARE

Who should use this application?

Application for someone who:

Is in a nursing home or ICF/IID (read more below)

Wants Home and Community Based Services (like CHOICES or Employment and Community First CHOICES)

Needs Hospice Care in a nursing home

Wants help paying for Medicare (like QMB or SLMB)

Mail this application to TennCare Connect, P.O. Box 305240 Nashville, TN 37230-5240. Or fax it to

855-315-0669. If you don’t need long term services and supports or help with your Medicare costs but you want to

You can give a trusted person permission to:

∙ talk about this application and your health care with us, ∙ see your information,

∙ act for you on matters related to this application and your coverage (including getting information about this application),

receive all notices or other communications about your application, ∙ and sign this application on your behalf.

This person is called an “authorized representative.” If you ever need to change your authorized representative, contact TennCare Connect at 855-259-0701. If you’re a legally appointed representative for someone on this application, submit proof with the application (if you haven’t already given us this proof). You must also

complete and send us the TennCare Authorized Representative – Individual page found on our website at

https://tn.gov/tenncare/topic/hipaa-forms.

If yes, then tell us: Their name _______________________________________________________________

Their phone number: (______) ________________________ - or - (_______) __________________________

Address: __________________________________________ Apartment or Suite Number_________________

City: ________________________________________ State: ___________ Zip Code: ___________________

E-Mail Address: ______________________________ ID Number (if applicable): _______________________

Organization name (if applicable): _____________________________________________________________

Is it okay for us to talk to this person about your case?

Yes

No

TC0131 Rev: 30Oct18

RDA 2047

If you need help, call 855-259-0701. It’s a free call.

LTSS and MSP APPLICATION.3

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1.Tell us WHO you are, WHERE you live and WHERE you get your mail.

Name: ____________________________________________________________________________________

Home address (NOT a P.O. Box): ______________________________________________________________

City: ________________________________________ State: ___________ Zip Code: ___________________

Mailing address, if different: __________________________________________________________________

City: ________________________________________ State: ___________ Zip Code: ___________________

Phone: (________) ___________-________________ - or - (________) ___________-___________________

Do you intend to be a Tennessee resident? Yes

No

You cannot receive TennCare Medicaid if you receive Medicaid benefits from another state. We can help tell

the other state you want to stop your Medicaid in that state. We will only contact the other state if you would be eligible for TennCare Medicaid. If you don’t want our help, you will need to end out-of-state Medicaid

before you get TennCare Medicaid.

Do you receive Medicaid benefits in another state? Yes

No

If yes, do you want us to ask that state to stop your Medicaid? Yes

Please answer these questions:

If yes, which state? ____________________

No

What’s the best time to reach you by phone? _____________________________________________________

I am using this application to apply for:

Help paying for Nursing Home care

Home and Community Based Services (HCBS) for older adults and adults with physical disabilities

Do you think you need care at home to keep from going into a nursing facility? Call your Area Agency on Aging and Disability at 866-836-6678. You still need to finish this application, but they can help you.

Medicare Savings Program to help with my Medicare costs

Hospice Services in a nursing home

Care in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)

Home and Community Based Services (HCBS) for Individuals with Intellectual and/or other Developmental Disabilities like Employment and Community First CHOICES

Do you think you need care at home to keep from going into a nursing facility? Then you must also complete an online referral at: https://tcreq.tn.gov/tmtrack/ecf/index.htm.

If you need help, call the Department of Developmental and Intellectual Disabilities in the area where you live:

West TN: 866-372-5709,

Middle TN: 800-654-4839, or

East TN: 888-531-9876.

Keep reading. You still need to finish this application.

Are you homeless now? Yes No

What language do you speak best?

What language do you read best?

Do you have a disability? Yes No

 

Are you living in a shelter? Yes

No

English

Spanish

Other Language ______________

English

Spanish

Other Language ______________

If yes, what is it? ___________________________________

If you do, do you need us to help you with these papers? Yes

No

TC0131 Rev: 30Oct18

RDA 2047

If you need help, call 855-259-0701. It’s a free call.

LTSS and MSP APPLICATION.3

Page 3 of 9

2.Tell us everyone who lives in your home now. Tell us who they are even if

they don’t have TennCare or if they don’t want TennCare. List yourself first. You can add more pages if you need to.

Is there someone living with you that wants TennCare but does not want long term services and supports? They must apply online at www.healthcare.gov. Or, they can call TennCare Connect at 855-259-0701.

Who lives in your home now?

Does this

Date of

Social Security number:

How is this

Sex

Want to tell

List yourself first.

person want

Birth

ONLY if

person related

 

us your Race?

Full Name

to qualify for

(Month/

this person wants

to you?

M /F

***

coverage

Day/Year)

coverage

 

 

(W, B, Y,

First, Middle Initial, Last

listed on the

 

 

 

 

A, H, I or O)

 

previous

 

 

 

 

 

 

page?

 

 

 

 

 

 

Yes

 

 

 

 

 

 

No

 

 

 

 

 

 

Yes

 

 

 

 

 

 

No

 

 

 

 

 

 

Yes

 

 

 

 

 

 

No

 

 

 

 

 

 

Yes

 

 

 

 

 

 

No

 

 

 

 

 

***If you want to tell us your race, please use these letters.

A = Asian H = Native Hawaiian or Pacific Islander

W = White

B = Black or African-American

Y = Hispanic

I = American Indian or Alaskan Native

O = Other

3.Answer these questions about you and all the people living in your home.

Are you a U.S. citizen, legal alien or eligible immigrant? Yes

No

INS papers.

If no, we will need a copy of your

Does any child living in your household have a parent who doesn’t live there too?

Yes No

If yes, which child? __________________What is the parent’s name of that child?____________

Does anyone living in your household have a spouse (a husband or wife) who doesn’t live there too?

Yes

No

If yes, who? _________________________________________________

Why does this person not live in this home? ______________________________________________________

Are you getting care in a nursing home? Yes

No

If yes, what’s the name of the nursing home? _______________________________________________________

When did you start getting care in the nursing home? _________________________________________________

Are you temporarily living out-of-state? Yes

No

If yes, tell us where you’re living and why. _____________________________________________________

To get TennCare, you must prove that Tennessee is your permanent home and you are coming back. Send us proof that Tennessee is your permanent home. Your proof can be something like:

Proof that you own or rent a home in Tennessee

Property tax statement for Tennessee

Your vehicle registration (from Tennessee)

Your voter’s registration (from Tennessee)

What city and county do you live in when you are in Tennessee? __________________________________

Do you own or lease a place to live in another state? Yes

No

Which state? _________________

Is anyone a Veteran or in Active Military status? Yes

No

 

If yes, tell us who. Be sure to tell us their name and social security number.

___________________________________________

_________________________________________

___________________________________________

_________________________________________

TC0131 Rev: 30Oct18

 

RDA 2047

If you need help, call 855-259-0701. It’s a free call.

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Do you have other health insurance, including Medicare? If so, tell us:

What is the name of the insurance company? __________________________________________________

What is the policy number? ________________________________________________________________

What is the policyholder’s name? ___________________________________________________________

What is the policyholder’s SSN? ____________________________________________________________

What is the premium amount? ______________________________________________________________

What is the start date? _____________________________________________________________________

What is the relationship of the policy holder to you and others on this application? _____________________

______________________________________________________________________________________

Do the other people listed in number 2 also have this insurance? Yes

No

If yes, tell us the names of the other people who are covered by this same health insurance plan:

___________________________________________

_______________________________________

___________________________________________

________________________________________

Do you (or other people listed in number 2) have health insurance other than the policy listed above? If so, please include the information about that policy on another piece of paper.

4. Send proof of your income.

Does anyone in your home work? Yes

 

No

If yes, you can send copies of pay stubs or proof of

earnings for the last 2 months for each job. What if you don’t have all your pay stubs for the last 2 months?

Give TennCare copies of all that you have.

 

 

 

 

 

 

 

 

Is anyone self-employed? Yes No

 

If yes, tell us the kind of work they do.____________________

If yes, send copies of their last federal income tax return with all schedule attachments. If you don’t have your tax forms, send other proof. Send something that shows your income and expenses.

Remember - Don’t send the original. Send a copy.

Tell us about any work you get paid for, even odd jobs where you don’t pay taxes.

Name of person

# of

How much

 

How

Name of Employer

 

Phone number of

 

(Who earns this

hours

do they get

 

often do

 

 

 

 

Employer

 

money?)

worked

before taxes

 

they get

(Are you self-employed? Tell us the

 

 

 

 

each

each pay

 

paid? ***

name of your business if it has one.)

 

 

 

 

week

period?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*** Daily, Weekly, Every 2 weeks, Twice a month, Monthly

Is there an adult in your home with no income? Yes

No

If yes, who? __________________

When did their income stop? ____________

 

How do they pay the cost of daily living?

For example, living with a

friend or relative, rent is paid by someone, living off savings, etc. ___________________________________

Does anyone get Social Security or SSI or Unemployment payments from Tennessee?

Yes

No

If yes, tell us who. _____________________________________________________________

You don’t have to send proof of this income. We’ll get it for you.

Did you lose Medicare because you went back to work and were making more money than your Social Security income limit? Yes No

TC0131 Rev: 30Oct18

RDA 2047

If you need help, call 855-259-0701. It’s a free call.

LTSS and MSP APPLICATION.3

 

Page 5 of 9

Does anyone get any of the kinds of income listed below? Yes No

Money from friends or relatives

Workers’ Compensation

Retirement Payments

Interest/Dividends/Royalties

Disability Payments

Rental Income

Child Support Payments

Alimony

Unemployment Payments from another state

Other

Veteran’s Benefits

If yes, tell us about it in the box below and send proof. Don’t send the original. Send a copy.

Name of person

What

How much

How often?

Who pays them?

What is their

(Who gets this money?)

kind?

do they get?

 

Phone Number?

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

5.Tell us if you pay for child care or care for a disabled adult.

Does anyone pay for child care or care for a disabled adult? Yes No

If yes, fill in the boxes below. Send proof that shows who gives the care and how much you pay them. This proof must be signed by the person that gives this care. It must say how much you pay and how often.

Who gets this care?

Who pays for this

How much

How often do

Name and Phone Number of Caregiver

 

care?

does it

you pay?

 

 

 

cost?

 

 

 

 

$

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

6.Tell us what you own. If you need more room, you can add more pages.

You must tell us what you own. What if you don’t tell us about what you own or you’re over the limit? You won’t qualify for TennCare Medicaid in any group that has a resource limit.

 

Do you own:

 

What’s it

How much do you

The kind of proof

 

 

 

worth now?

owe on it?

we need:

 

 

 

 

 

 

 

Property Tell us these things about the

 

 

 

Something that shows what

 

property in the space below:

 

 

 

 

it’s worth like a property tax

 

 

 

 

 

 

statement

 

 

 

 

 

 

and something that shows

 

Street Address:

 

$

$

 

how much you owe like a

 

City:

 

 

 

 

 

 

 

 

 

mortgage statement

 

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

$

$

 

 

 

City:

 

 

 

 

 

 

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you own:

 

What’s it

How much do you

The kind of proof

 

 

 

worth now?

owe on it?

we need:

 

 

 

 

 

 

 

 

Checking accounts

 

$

 

 

Statement from bank or

 

Bank Name: _____________________

 

 

 

credit union that shows the

 

 

 

 

 

 

balance

 

Savings or credit union accounts

$

 

 

 

 

 

 

 

Bank Name: _____________________

 

 

 

 

 

Christmas Club accounts

 

$

 

 

 

 

Bank Name: _____________________

 

 

 

 

 

TC0131 Rev: 30Oct18

 

 

 

 

RDA 2047

If you need help, call 855-259-0701. It’s a free call.

LTSS and MSP APPLICATION.3

 

 

 

 

Page 6 of 9

 

 

 

 

 

 

 

 

Cars and trucks

 

 

 

 

 

 

 

Tell us the make, model and year below.

 

 

 

 

 

Make_________________________

$

 

$

 

 

Model

Year

 

 

 

 

 

Make_________________________

$

 

$

 

 

Model

Year

 

 

 

 

 

 

 

 

 

 

 

 

Make_________________________

$

 

$

 

 

Model

Year

 

 

 

 

 

 

 

 

 

 

 

Payment book or signed

Motorcycles and boats

 

 

 

 

Make_________________________

$

 

$

 

statement that says how

 

 

much you owe

Model

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Make_________________________

$

 

$

 

 

Model

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

RVs and campers

 

 

 

 

 

 

 

Make_________________________

$

 

$

 

 

Model

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

Trust fund or Estate

 

 

$

 

 

 

Copy of legal papers

 

 

 

 

 

 

 

Stocks

 

 

Current

 

 

 

Bank or investment

Name:________________________

value:

 

 

 

company papers that show:

Number Owned: _______________

$

 

 

 

the kind of stock or

 

 

 

 

Bonds

 

 

Current

 

 

 

bonds,

Name:________________________

value:

 

 

 

how many you own of

$

 

 

 

Number Owned: ________________

 

 

 

each kind, and

 

 

 

 

 

 

 

 

 

 

 

 

 

 

how much they’re worth

IRAs and Keogh Plans

Account

 

 

 

Statement that shows the

 

 

 

value:

 

 

 

balance. Are you drawing off

 

 

 

$

 

 

 

this amount? Yes No

 

 

 

 

 

 

 

If yes, how much? $

 

 

 

 

 

 

 

Savings Certificates or CDs

$

 

 

 

Statement from bank that

Tax Shelter Accounts

 

 

$

 

 

 

shows the balance

Revocable burial contract

$

 

$

 

Copy of the burial contract

Irrevocable burial contract

$

 

$

 

Copy of the burial contract

 

 

 

 

 

 

 

 

Cemetery Lots

 

 

$

 

$

 

A deed and something from

How many? __________

 

 

 

 

the cemetery that shows how

Are the lots for you or members of your

 

 

 

 

much you could sell the lots

immediate family? Yes

No

 

 

 

 

for now

If no, for who?_________________

 

 

 

 

 

Other (Tell us what):

 

 

$

 

$

 

 

 

 

 

 

 

 

 

Does anyone in your household have a life insurance policy? Yes

No

 

 

 

 

Tell us who

 

What is its cash value?

Insurance Company Name and Phone Number

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

TC0131 Rev: 30Oct18

RDA 2047

If you need help, call 855-259-0701. It’s a free call.

Yes No

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Page 7 of 9

7.ONLY fill out this part if you:

need care in a long term care facility, even if you can be served safely in your home.

need care at home to keep from going into a long term care facility.

have an intellectual or developmental disability and need care in the community.

need care in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID).

In the last 60 months (5 years), have you sold or given away any of the kinds of things

listed in question 6? Yes No

If yes, fill in the boxes below.

 

 

 

 

 

 

 

What did you sell or

What was it

 

How much did

If you sold

The kind of proof

give away?

worth?

 

you owe on it?

it, how

we need:

 

 

 

 

much did

 

 

 

 

 

you get?

 

 

$

 

$

$

Something that shows:

 

 

 

 

 

how much it was worth, and

 

$

 

$

$

 

 

 

 

 

how much you owed on it,

 

$

 

$

$

 

 

 

 

 

and

 

$

 

$

$

 

 

 

 

 

how much you sold it for

In the last 12 months (1 year) has anyone in your household gotten a lump sum of money? This could be something like an insurance settlement, back pay for Social security, or a lottery prize.

If yes, fill in the boxes below.

Tell us who

How much did

Where did it come from?

The kind of proof

 

this person get?

 

we need:

 

$

 

Bank records or an award

 

 

 

letter that shows how much

 

$

 

 

 

you got.

 

 

 

 

$

 

 

 

 

 

 

 

 

If you’re applying for CHOICES or Employment and Community First, or Hospice care, you can choose your health plan. If you don’t pick one, TennCare can pick for you. If you’re approved, your approval letter will tell

you who your plan is and how you can change it. The health plans for TennCare are: AmeriGroup, BlueCare, and UnitedHealthcare.

I want my health plan to be:___________________________________________________________________

(Are you applying to get help with your Medicare costs only? If so and you are approved for a Medicare Savings Program like QMB or SLMB you won’t be enrolled in a TennCare health plan.) But TennCare will pay your

Medicare premium for you.

8.Sign here.

I am giving my OK for TennCare to get facts about me and my family. They can get it from other people or agencies. This includes government agencies, employers and places we get health care.

The information I gave on this application is true and complete as far as I know. What if I gave information that’s not true or held back facts on purpose? I could go to jail or have to pay TennCare back. I could also be charged with a crime like perjury or a felony.

Sign Here X: ________________________________________

Date: ________________________

Person Applying / Head of Household

 

Witness Sign Here (if person applying is unable to sign) X: __________________________________________

Witness Print your name: ____________________________________

Date: ________________________

TC0131 Rev: 30Oct18

RDA 2047

If you need help, call 855-259-0701. It’s a free call.

LTSS and MSP APPLICATION.3

Page 8 of 9

Use this checklist to make sure you are giving us everything we need to work your application. Having all of the information we need will help us work your application faster.

(1) ID and citizenship (i.e. driver’s license and birth certificate) for you, the applicant.

(2) Social Security Number and date of birth for you, the applicant. (This information is optional for your spouse. But, if you can give us his/her SSN and date of birth now, it will help us work your application faster.)

(3) Bank statements for the month of application and two months before that (for each account checking, savings, IRAs, CDs, stocks, bonds, and 401Ks).

(4) Life insurance policies (owned by you, the applicant, and your spouse) showing company name, address, policy numbers, date issued, face value, and cash value for each policy.

(5) Health insurance premium(s) including Medicare Supplemental or Medicare Part D Plans.

(6) All gross income for you, the applicant, and your spouse (i.e. Pension, VA Pension, or VA Aid & Attendance, Rental Income, Alimony, etc.)

(7) Vehicle registration (make, model and year), including recreational vehicles.

(8) Property owned (county, address and value), including the home you live in now or lived in before entering a nursing home.

(9) Prepaid burial contracts, including an itemized statement for goods and services and if it’s revocable or irrevocable.

(10) Basic living expenses for your spouse:

Rent or mortgage

Utilities

Property tax

Homeowner’s insurance

(11) All questions in the application have been answered about any dependent children (including disabled adults) who live with you.

(12) Names, phone numbers, and address of two friends or relatives. These are people who can verify you are who you say you are.

(13) All proof of the sale or transfer of any resource made in the last five (5) years (realty, financial, etc.)

(14) Value of Cemetery plots

(15) Marriage certificate (if currently married not widow/widower)

The items checked above are attached along with your application for Medicaid. Items that are not checked are still needed. Were you asked for items that are not listed above? If so, please tell us the items you are still trying to get:

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

____________________________________________

You may be asked to provide more information after the phone interview. The eligibility worker will explain what is needed, how to get it, and will help you get it if you ask.

***Important: The application for Medicaid must be signed. It will take longer for us to process the application if its not signed. Be sure to send us this page with the application.***

TC0131 Rev: 30Oct18

RDA 2047

If you need help, call 855-259-0701. It’s a free call.

LTSS and MSP APPLICATION.3

Page 9 of 9

Your Rights and Responsibilities

Keep this page for your records.

Do you need help filling out these pages? Do you have questions?

Call 855-259-0701. It’s a free call.

Do you need help in another language? Let us know. TennCare will get you a free interpreter.

Anyone who wants TennCare must be:

A U.S. citizen or

Legally admitted to the U.S. for permanent residence.

TennCare will use your Social Security numbers to get facts about you and your income.

Those facts will be used to prove you can have TennCare. They will not be used to deport you.

TennCare may give your Social Security numbers to:

Police who are looking for lawbreakers;

Other state or Federal Agencies (but not the INS); and

Collection agencies working to collect money owed to the State.

I’m signing this application under penalty of perjury which means I’ve provided true answers to all the questions on this form and its supplements to the best of my knowledge. I know that I may be subject to penalties under state and federal law if I provide false and or untrue information.

You must tell TennCare Connect if anything changes (and is different than) what you wrote on this application within 10 days of that change. You can call 855-259-0701 to report any changes. You understand that a change in your information could affect the eligibility for member(s) of your household.

Under federal law, discrimination isn’t permitted on the basis of race, color, birthplace, language, sex, age, religion, or disability. If you think you have been treated unfairly, call 855-259-0701 to report it. It’s a free call.

If you are approved, you can’t keep any health insurance or medical payments you get from insurance or other companies. Those payments belong to the State. You must sign them over to the State

What if the Tennessee Bureau of Investigation, the TennCare Office of the Inspector General or another agency asks for your help catching TennCare fraud and abuse? You must help.

If the State pays for medical bills or for nursing home care for you, the State may get that money back. When you die, the State may take money that you owe from your estate.

No one else can use your TennCare card. What if you let someone else use your card? You may have to pay the State back for that other person’s medical bills.

You are giving TennCare your OK to get facts about you and your family from others. This includes government agencies, employers and places you get health care.

If TennCare says you can’t keep TennCare, you can appeal. The letter you get will tell you how to appeal.

If you want to register to vote, you can complete a voter registration form at https://sos.tn.gov/products/elections/register-vote.

TC0131 Rev: 30Oct18

RDA 2047

If you need help, call 855-259-0701. It’s a free call.