Eligibility Reference Guide - Tennessee

1 Family Size100%120%133%135%142%195%200%211%250% 1Mo$1,012 $1,214 $1,346 $1,366 $1,437 $1,973 $2,024 $2,135 $2,530 Yr$12,140$14,568 $16,147 $16,389 $17,239 $23,673 $24,280 $25,616 $30,350 2 Mo$1,372 $1,646 $1,825 $1,852 $1,948 $2,675 $2,744 $2,895 $3,430 Yr$16,460 $19,752 $21,892 $22,221 $23,374 $32,097 $32,920 $34,731 $41,150 3 Mo$1,732 $2,078 $2,304 $2,338 $2,459 $3,377 $3,464 $3,654 $4,330 Yr$20,780 $24,936 $27,638 $28,053 $29,508 $40,521 $41,560 $43,846 $51,950 4 Mo$2,092 $2,510 $2,782 $2,824 $2,971 $4,079 $4,184 $4,414 $5,230 Yr$25,100 $30,120 $33,383 $33,885 $35,642 $48,945 $50,200 $52,961 $62,750 5 Mo$2,452 $2,942 $3,261 $3,310 $3,482 $4,781 $4,904 $5,174 $6,130 Yr$29,420 $35,304 $39,129 $39,717 $41,777 $57,369 $58,840 $62,077 $73,550 6 Mo$2,812 $3,374 $3,740 $3,796 $3,993 $5,483 $5,624 $5,933 $7,030 Yr$33,740 $40,488 $44,875 $45,549 $47,911 $65,793 $67,480 $71,192 $84,350 7 Mo$3,172 $3,806 $4,219 $4,282 $4,504 $6,185 $6,344 $6,693 $7,930 Yr$38,060 $45,672 $50,620 $51,381 $54,046 $74,217 $76,120 $80,307 $95,150 8 Mo$3,532 $4,238 $4,698 $4,768 $5,015 $6,887 $7,064 $7,452 $8,830 Yr$42,380 $50,856 $56,366 $57,213 $60,180 $82.

2 641 $84,760 $89,422 $105,950 Annual and Monthly income in DollarsNote: For each additional person add $4,320 Tennessee Medicaid Coverage Groups and Eligibility RequirementsThese two charts set forth the income and resource levels that applicants must meet before they can be determined eligible for of FPLF amiliesW omenAged,Blind orD isabledA ge 0-1195A ge 1-5142A ge 6-19133A ge 0-19 TennCare Standard250%Pregnant195 FormerFost erC are75 SSI Active/Related224 Long Term CareQMB100 SLM B120QI1135 QDW I200M edicareC ostSharing211A ge 0-21 Medically NeedyPregnant Medically NeedyFormer Foster Care Up To Age 260%Breast or Cervical CancerCaretaker RelativeTransitional185 Med.

3 LimitChildrenAge 0 - 19 Low income children age 0 up to 1st birthday 195% of poverty - No resource testLow income children age 1 to 6th birthday 142% of poverty - No resource test Low income children age 6 to 19th birthday133% of poverty - No resource test Child Medically Needy Children up to age 21. Must either have low income or have sufficient unreimbursed medical bills to spend down to requisite income limits. Monthly spend-down levels of $241 (1), $258 (2), $317 (3), $325 (4), $392 (5), $408 (6), or $467 (7)Resource: $2,000 (1), $3,000 (2), add $100 per additional individual Standard UninsuredChildren under age 19 who do not have access to insurance.

4 Category is only open to children who lose Medicaid Eligibility and rollover into Standard. Below 211% of poverty No resource testStandard Medically Eligible Children under age 19 who do not have access to insurance and who have health conditions that make the child uninsurable. Category is only open to children who lose Medicaid Eligibility and rollover into Standard. Above 211% of povertyCoverKidsAvailable to children under age 19 and to the unborn children of women not eligible under another TennCare TennCare income limits and below 250% of povertyNo resource testFamiliesCaretaker RelativeAvailable to parents and caretaker relatives of dependent children under age income levels of $1018 (1), $1329 (2),$1611 (3), $1867 (4), $2102 (5), $2320 (6), or $2524(7)

5 No resource testTransitional/Extended Medicaid Children, pregnant women, and caretaker relatives who lose Medicaid due to an increase in income or spousal of poverty during months 7 - 12 WomenPregnantLow income pregnant : Newborns born to Medicaid eligible women are deemed eligible for one year. 195% of povertyNo resource test Breast or Cervical Cancer Women under 65 who are not eligible for any other category of Medicaid and have been diagnosed as the result of a screening at a Centers for Disease Control and Prevention (CDC) of povertyNo resource test Pregnant Medically NeedyPregnant either have low income or have sufficient unreimbursed medical bills to spend down to requisite income limits.

6 Monthly spend-down levels of $241 (1), $258 (2), $317 (3), $325 (4), $392 (5), $408 (6), or $467 (7)Resource: $2,000 (1),$3,000 (2), add $100 per additional individual Aged, Blind & DisabledSSI (Supplemental Security income ) Active: Low income aged, blind, or disabled recipients of federal SSI cash payments as determined by SSA$750 per month (1), $1,125(2) Resource: $2,000 (1), $3,000 (2)Long Term CareLow income individuals who require care in a nursing facility or intermediate care facility for individuals with intellectual disabilities or who receive Home and Community-Based Services in their home.

7 $2,250 per monthResource: $2,000 SSI-Related (Pickle/Pass Along, Disabled Adult Child, Widow/ Widower)Pickle/Pass Along: Lost SSI since 1977 due to OASDI cost-of-living increase. DAC: Lost SSI since 1987 due to receipt/increase of DAC benefits. Widow/Widower: Lost SSI due to receipt of OASDI from deceased spouse.$750 per month (1), $1,125 (2)Resource: $2,000 (1), $3,000 (2)Adults Foster CareFormer Foster Care Up To Age 26 Individuals under age 26 who aged out of foster care in Tennessee and who received TennCare Medicaid at that income or resource testMedicare Cost SharingQMBQ ualified Medicare BeneficiaryTennCare pays Medicare premiums, deductibles and co-insurance for those eligible for of povertyResource: $7,560 (1), $11,340 (2)SLMBS pecified Low income Medicare Beneficiaries TennCare pays Medicare Part B premiums to 120% of povertyResource.

8 $7,390 (1), $11,090 (2) QI 1 Qualified Individuals TennCare pays Medicare Part B premiums to 135% of povertyResource: $7,560 (1), $11,340 (2)QDWIQ ualified Disabled Working Individual TennCare pays Medicare Part A buy-in for non-aged individuals who lost SSI disability benefits and premium free Part more than 200% of povertyResource: $4,000 (1), $6,000 (2)