Guidance for Renewal Packet

Transcription

1 Guidance fr Renewal Packet This dcument is meant t prvide guidance t individuals cmpleting r assisting with cmpletin f renewal packets received in the mail fr redeterminatin. Individuals must use the bar-cded renewal packet received in the mail. If an individual needs a reprint f the renewal packet, the individual shuld call TNHC t request a reprint. Step 1 The infrmatin in Step 1 is an adult (age 18 r lder) wh is the pint f cntact fr the renewal packet. This persn may r may nt have TennCare. If he des nt have TennCare but is cmpleting the packet fr the member, the member will be listed later in Step 2. Step 1 shuld be cmpleted with all cntact infrmatin available fr the adult pint f cntact. If the renewal packet is fr a child getting cverage, the infrmatin in Step 1 shuld be fr the adult respnsible fr the child. Hwever, if the renewal packet is fr the adult, she shuld list her name and cntact infrmatin. This sectin shuld be cmpleted as fully as pssible t ensure TennCare is able t reach the member, r an adult acting n behalf f the member, fr any additinal infrmatin needed. Remember, if the adult pint f cntact in Step 1 is cmpleting this packet fr the TennCare member, the TennCare member s infrmatin will be entered later in Step 2. Otherwise, the State will be unable t renew the cverage fr the member. Step 2 Step 2 shuld be cmpleted as fully as pssible fr each persn in the husehld. If there are mre than 2 peple in the husehld, make cpies f Step 2 Persn 2 (pages 5 and 6). Then cmplete thse pages fr each additinal persn. Step 2 Persn Persn 1 is the adult pint f cntact in the member s husehld. Persn 1 may als be the adult wh has TennCare nw and has been selected fr renewal. Persn 1 shuld prvide cmplete infrmatin fr questins 1-4, which includes the fllwing: First name, middle name, last name & suffix (Jr., Sr, III) Date f birth Sex (Male/Female) 5 Persn 1 s Scial Security Number (SSN) shuld be prvided t help us renew the member s eligibility mre quickly. There are sme exceptins fr prviding a SSN, but if Persn 1 has an SSN, that infrmatin shuld be prvided. 6 Persn 1 shuld tell us if they plan t file a federal incme tax return NEXT YEAR. This is nt based n if Persn 1 previusly filed taxes, it s asking if Persn 1 plans t file taxes during the next tax seasn. If yes: If Persn 1 plans t file taxes, Persn 1 shuld list all tax dependents that will be claimed. The fllwing shuld be prvided fr each tax dependent: Full name (first, middle initial, last) Page 1 f 19

2 If n: If Persn 1 des nt plan t file taxes, but will be claimed as a tax dependent Persn 1 needs t tell us the fllwing: Full name (first, middle initial, last) f the persn (the tax filer) that will claim Persn 1; The tax filer s relatinship t Persn 1 (tax dependent); If Persn 1 is living with the persn (the tax filer) that will claim them. If Persn 1 is nt sure abut plans t file taxes, Persn 1 may indicate n t questin 6. 7 If Persn 1 is pregnant they must als tell us the fllwing: The number f babies expected; The expected due date. 8 If Persn 1 des nt have TennCare nw, this renewal frm cannt be used t apply fr TennCare. T apply fr TennCare, g t healthcare.gv r call the Federally Facilitated Marketplace at Additinally, a persn may apply fr new cverage by mail by printing ff the paper applicatin at and mailing it t Health Insurance Marketplace Dept. f Health and Human Services 465 Industrial Blvd Lndn, KY IMPORTANT: Persn 1 shuld cntinue t Questin 9 nly if she answered yes t Questin 8. If Persn 1 answered n t Questin 8 and des nt have TennCare nw, he shuld prceed t the incme questins n page 4. The incme questins n page 4 must still be cmpleted as this infrmatin will affect the eligibility f ther members f the husehld wh are able t use this packet fr cntinued eligibility Answering yes t any f these questins indicates that Persn 1: Needs nursing hme care in a nursing hme r at hme; Has Medicare and want help with Medicare cst sharing; Needs hspice care; Has gtten SSI and Scial Security in the same mnth since 1977, and still get Scial Security; r Is pregnant r under age 21, and have bill fr medical care in the last 3 mnths (paid r unpaid Additinally, a yes t these questins may require prf f resurces be submitted (things wned by the member r a persn in the husehld, such as vehicles, bank accunts, prperty). IMPORTANT: Persn 1 wh answers yes t questins 9-13 must als fill ut Appendix A with the cmpleted renewal packet and send bth f these fr review. Questins must be answered with the apprpriate selectin. If 14 is n fr US citizen r US natinal is indicated, but 15 is yes indicating an eligible immigratin status, Persn 1 shuld prvide all applicable numbers/ids t ensure eligibility status can be cnfirmed. 16 Fr questin 16, if Persn 1 is living with and is the main persn caring fr a child under 18 r is caring fr an 18 year ld still in schl full time, he shuld answer yes. 17 If Persn 1 is age 22 r yunger and is a full-time student, she shuld answer yes t If Persn 1 aged ut f fster care at age 18 r lder in Tennessee, he shuld answer Page 2 f 19

3 yes t If Persn 1 is a wman under 65 wh is currently getting treatment fr breast r cervical cancer, she shuld answer yes t 19. Additinally, if Persn 1 has nt been screened fr breast r cervical cancer but thinks she might need screening, she shuld cntact the Health Department: Current Jb and Incme Infrmatin The crrect ptin shuld be checked fr Persn 1; nt emplyed, self-emplyed, r emplyed If Persn 1 currently has ne jb, questins shuld be cmpleted. Additinally, pay stubs, tax frms (1040 r W-2 fr 2015), r any ther prf f wrk and incme shuld be returned with the packet. If Persn 1 currently has tw jbs, questins shuld be cmpleted: Emplyer name, address, and phne number: Persn 1 shuld enter the infrmatin fr the current lcatin where she is wrking. Wages/tips (befre taxes): This will be the amunt shwing n Persn 1 s pay stubs befre taxes are taken ut with any tips added t the ttal. Tips and ther cash incme frm jbs: include all tip incme, even if it s nt reprted t the emplyer. Hw ften: Persn 1 shuld chse the ptin that she receives the amunt listed in the wages/tips field: hurly, weekly, every 2 weeks, twice a mnth, mnthly, r yearly. If she is paid thrugh a ne-time cntract, she can select yearly. Amunts that change weekly: if the incme amunt changes each week, enter hw much Persn 1 expects t earn fr the whle mnth, r enter the average number f hurs Persn 1 is wrking right nw. Average hurs each week: Persn 1 shuld enter the number f hurs she usually wrks in a week. Include all jbs, even if they re part-time r paid in cash. Additinally, pay stubs, tax frms (1040 r W-2), r any ther prf f wrk and incme shuld be returned with the packet. Persn 1 desn t need t include amunts that an emplyer takes ut f a paycheck fr child care, health insurance, r retirement plans that are nt taxable. Smetimes these are called pre-tax deductins. The pay stub shuld list these deductins individually. Dn t include these amunts in the pay listed. The pay stub may federal taxable wages, which subtracts the pre-tax amunts frm grss wages. If this amunt is listed n the pay stub, use it t reprt pay. Fr questin 30, Persn 1 shuld select any f the ptins ccurring within the last year fr her: change jbs, stp wrking, r start wrking fewer hurs. If nne f these apply, she shuld select nne f these. 31 Questin 31 relates t incme that is earned thrugh self-emplyment. This is the net incme Persn 1 earns frm his wn trade r business. Fr example, any net incme Page 3 f 19

4 (prfit) earned frm gds sld r services prvided t thers cunts as self-emplyment incme. If Persn 1 selects self-emplyment, he shuld describe the kind f wrk. There s n special frmat just a simple descriptin f the wrk is needed. Fr example, if he cleans huses, huse cleaning culd be entered. If he makes jewelry, jewelry making culd be entered. If he wrks n cnstructin prjects, cnstructin culd be entered. T enter the net incme frm self-emplyment, he shuld enter an amunt that includes the net incme r net lss frm self-emplyment. Net incme grss incme frm any trade r business minus allwable deductins fr that trade r business. Allwable deductins include expenses paid t perate the business r participate in the trade, including: Car and truck expenses (fr travel during the wrk day, nt cmmuting) Depreciatin Emplyee wages and fringe benefits Prperty, liability, r business interruptin insurance Interest n lans fr yur business (including mrtgage interest paid t banks) Legal and prfessinal services Rent r lease f business prperty and utilities Cmmissins, taxes, licenses, and fees Advertising Cntract labr Repairs and maintenance This incme shuld be reprted and prf f the incme shuld be included when the packet is returned. This can include pay stubs, tax frms (such as the Schedule SE, Schedule C r Schedule F), r any ther type f prf f the amunts received and hw ften they are received. 32 Questin 32 shuld include incme nt included in the current jb sectin f the renewal, but shuld nt include child supprt, Veteran s payments r Supplemental Security Incme (SSI). If there is n incme ther than incme already prvided in the current jb sectin Persn 1 shuld select nne. Otherwise, Persn 1 shuld tell us hw much and hw the fllwing is received if applicable: Unemplyment Unemplyment cmpensatin includes any amunt received under an unemplyment cmpensatin law f the United States r a state. Persn 1 must include unemplyment benefits (including frm an emplyer r unin) as incme. Pensins A pensin is a payment r series f payments made t a persn after he r she retires frm wrk. Generally, the amunt f the incme frm a pensin accunt distributin depends n the type f pensin accunt, hw much was cntributed t the pensin accunt, and whether the amunts cntributed were already taxed. Persn 1 des nt have t include a qualified distributin frm a designated Rth accunt as incme. Page 4 f 19

5 Scial Security These are the amunt a persn gets frm Scial Security disability, retirement (including railrad retirement (RRB)), r survivr s benefits each mnth. Enter the full amunt befre any deductins, like Medicare premiums, incme tax withhlding, verpayments, child supprt, r alimny. Dn t enter Supplemental Security Incme (SSI) benefits. Retirement Accunts A retirement benefit is a payment r series f payments made t a persn after he r she retires frm wrk. Generally, the amunt f the incme frm a retirement accunt distributin depends n the type f retirement accunt, hw much was cntributed t the retirement accunt, and whether the amunts cntributed were already taxed. Persn 1 des nt have t include a qualified distributin frm a designated Rth accunt as incme. Alimny received Alimny received is mney a persn gets frm a spuse she n lnger lives with, r a frmer spuse, if paid as part f a divrce agreement, separatin agreement, r curt rder. Payments designated in the agreement r rdered as child supprt r as a nn-taxable prperty settlement aren t alimny. Net Farming/fishing If this was already prvided in the renewal packet as self-emplyment incme, it shuld nt be listed again) If Persn 1 has incme frm farming r fishing, he can enter it as farming r fishing incme r self-emplyment incme, but he shuld nly enter it nce. A persn is in the business f farming if he cultivates, perates, r manages a farm fr prfit, either as wner r tenant. A farm can include livestck, dairy, pultry, fish, r fruit. It can als include plantatins, ranches, ranges, and rchards. Fishing incme includes amunts received frm catching, taking, harvesting, cultivating, r farming fish, shellfish, crustacean, spnges, seaweeds, r ther aquatic frms f animal r vegetable life, as well as mney frm patrnage dividends and fuel tax credits and refunds. Net rental/ryalty If this was already prvided in the renewal packet as self-emplyment incme, it shuld nt be listed again) Rental incme is the amunt smene pays t use a persn s prperty after prperty expenses are subtracted. Ryalty incme includes any payments received frm a patent, cpyright, r sme ther natural resurce wned. Other incme Any incme received nt already prvided n the renewal frm can be included here. Persn 1 des nt need t prvide incme frm child supprt, Veteran s payments r Supplemental Security Incme (SSI). Page 5 f 19

6 Other incme might include a ne-time payment received this mnth, such as a bnus r severance. Please prvide the amunt and hw ften the Other incme is received. If it s a ne-time payment be sure t say netime payment). Other incme may als include jury duty pay. If Persn 1 is being paid fr jury duty service, enter hw much he is getting, including reimbursement fr transprtatin. If the mney frm jury duty ges straight t Persn 1 s emplyer, dn t enter it here. Other incme may include Curt awards. If Persn 1 was invlved in and gt mney frm a lawsuit, the mney may be taxable. Examples f mney frm lawsuits that are isn t taxable are amunts awarded fr persnal physical injury r sickness and an amunt received as cmpensatin fr damages t the persn s prperty if the payment is less than the amunt paid fr the prperty. Payments t cmpensate a persn fr lst wages r punitive damages awards are examples f taxable curt awards. If ther incme is selected by a member f the clergy r a religius rder he shuld exclude the same incme excluded n the federal incme tax return. Other incme may include cash supprt, ptin if smene wh isn t the persn s parent r yur spuse claims them as a dependent fr taxes, and the tax filer is n renewal. Prvide the amunt f the cash supprt. Fr example, if the tax filer gives the persn $200 per mnth t help pay fr rent r ther living csts, include that amunt here. Dn t include in-kind supprt that the tax filer prvides, fr example, the value f rm and bard, r clthes purchased by the tax filer. Only enter cash supprt if the persn is a tax dependent f smene ther than a parent r spuse. Other incme may als include gambling, prizes, r awards: This includes lttery winnings. It desn t include prizes that aren t taxable, like mst academic schlarships. 33 There are certain expenses a persn can use t lwer his grss incme. These expenses are like expenses r deductins allwed by the IRS. Persn 1 desn t have t be a tax filer t get these deductins. Persn 1 shuld tell us abut these deductins in questin 33. Deductins already deducted ut f Self-emplyment incme shuld nt be reprted again here. Persn 1 shuld tell us abut the fllwing if applicable: Alimny paid: Persn 1 shuld tell us hw much they pay and hw ften. Student lan interest: The persn shuld tell us hw much they pay and hw ften. Other deductins: They shuld tell us hw much they pay and hw ften. Other deductins include expenses such as educatr expenses fr teachers wh pay fr supplies ut-f-pcket, mving expenses fr mving t live much clser t a jb, cntributins t an individual retirement accunt if the persn desn t have a retirement accunt thrugh a jb, r tuitin csts fr schl if csts are paid ut-fpcket and deducted n the tax return. Prf f deductins may include tax frm frms, curt rders, cancelled checks, etc., and this prf shuld be sent in with the renewal packet. Page 6 f 19

7 Remember, Step 2 shuld be repeated fr each additinal persn in the husehld. The instructins prvided belw are fr Persn 2 and each additinal persn that shuld be included. Step 2 Persn Fr Persn 2 prvide: Cmplete infrmatin fr questins 1-4, which includes the fllwing: First name, middle name, last name & suffix (Jr., Sr, III) Date f birth Sex (Male/Female) 5 Persn 2 s Scial Security Number shuld be prvided t help us renew the member s eligibility mre quickly. There are sme exceptins fr prviding a SSN, but if Persn 2 has a SSN, that infrmatin shuld be prvided. 7 Persn 2 shuld tell us if they plan t file a federal incme tax return NEXT YEAR. This is nt based n if Persn 2 previusly filed taxes, it s asking if Persn 2 plans t file taxes during the next tax seasn. If yes: If Persn 2 plans t file taxes, Persn 2 shuld list all tax dependents that will be claimed. The fllwing shuld be prvided fr each tax dependent: Full name (first, middle initial, last) If n: If Persn 2 des nt plan t file taxes, but will be claimed as a tax dependent Persn 2 needs t tell us the fllwing: Full name (first, middle initial, last) f the persn (the tax filer) that will claim Persn 2; The tax filer s relatinship t Persn 2 (tax dependent); If Persn 2 is living with the persn (the tax filer) that will claim them. If Persn 2 is nt sure abut plans t file taxes, Persn 2 may indicate n t questin 7. 8 If Persn 2 is pregnant they must als tell us the fllwing: The number f babies expected; The expected due date. 9 If Persn 2 des nt have TennCare nw, this renewal frm cannt be used t apply fr TennCare. T apply fr TennCare, g t healthcare.gv r call the Federally Facilitated Marketplace at Additinally, a persn may apply fr new cverage by mail by printing ff the paper applicatin at and mailing it t Health Insurance Marketplace Dept. f Health and Human Services 465 Industrial Blvd Lndn, KY IMPORTANT: Persn 2 shuld cntinue t Questin 10 nly if she answered yes t Questin 8. If Persn 2 answered n t Questin 9 and des nt have TennCare nw, he shuld prceed t the incme questins n page 6. The incme questins n page 6 must still be cmpleted as this infrmatin will affect the eligibility f ther members f the husehld wh are able t use this packet fr cntinued eligibility Answering yes t any f these questins indicates that Persn 2: Needs nursing hme care in a nursing hme r at hme; Page 7 f 19

8 15-16 Has Medicare and want help with Medicare cst sharing; Needs hspice care; Has gtten SSI and Scial Security in the same mnth since 1977, and still get Scial Security; r Is pregnant r under age 21, and have bill fr medical care in the last 3 mnths (paid r unpaid, Additinally, a yes t these questins may require prf f resurces be submitted (things wned by the member r a persn in the husehld, such as vehicles, bank accunts, prperty). IMPORTANT: Persn 2 wh answers yes t questins must als fill ut Appendix A with the cmpleted renewal packet and send bth f these fr review. Questins must be answered with the apprpriate selectin. If 14 is n fr US citizen r US natinal is indicated, but 15 is yes indicating an eligible immigratin status, Persn 2 shuld prvide all applicable numbers/ids t ensure eligibility status can be cnfirmed. 17 Fr questin 17, if Persn 2 is living with and is the main persn caring fr a child under 18 r is caring fr an 18 year ld still in schl full time, she shuld answer yes. 18 If Persn 2 is age 22 r yunger and is a full-time student, she shuld answer yes t If Persn 2 aged ut f fster care at age 18 r lder in Tennessee, he shuld answer yes t If Persn 2 is a wman under 65 wh is currently getting treatment fr breast r cervical cancer, she shuld answer yes t 20. Additinally, if Persn 2 has nt been screened fr breast r cervical cancer but thinks she might need screening, she shuld cntact the Health Department: Current Jb and Incme Infrmatin The crrect ptin shuld be checked fr Persn 2; nt emplyed, self-emplyed, r emplyed If Persn 2 currently has ne jb, questins shuld be cmpleted. Additinally, pay stubs, tax frms (1040 r W-2), r any ther prf f wrk and incme shuld be returned with the packet. If Persn 2 currently has tw jbs, questins shuld be cmpleted: Emplyer name, address, and phne number: Persn 2 shuld enter the infrmatin fr the current lcatin where he is wrking. Wages/tips (befre taxes): This will be the amunt shwing n Persn 2 s pay stubs befre taxes are taken ut with any tips added t the ttal. Tips and ther cash incme frm jbs: include all tip incme, even if it s nt reprted t the emplyer. Hw ften: Persn 2 shuld chse the ptin that he receives the amunt listed in the wages/tips field: hurly, weekly, every 2 weeks, twice a mnth, mnthly, r yearly. If he is paid thrugh a ne-time cntract, he can select yearly. Amunts that change weekly: if the incme amunt changes each week, enter hw much Persn 2 expects t earn fr the whle mnth, r enter the Page 8 f 19

9 average number f hurs Persn 2 is wrking right nw. Average hurs each week: Persn 2 shuld enter the number f hurs he usually wrks in a week. Include all jbs, even if they re part-time r paid in cash. Additinally, pay stubs, tax frms (1040 r W-2), r any ther prf f wrk and incme shuld be returned with the packet. Persn 2 desn t need t include amunts that an emplyer takes ut f a paycheck fr child care, health insurance, r retirement plans that are nt taxable. Smetimes these are called pre-tax deductins. The pay stub shuld list these deductins individually. Dn t include these amunts in the pay listed. The pay stub may federal taxable wages, which subtracts the pre-tax amunts frm grss wages. If this amunt is listed n the pay stub, use it t reprt pay. Fr questin 31, Persn 2 shuld select any f the ptins ccurring within the last year fr him/her: change jbs, stp wrking, r start wrking fewer hurs. If nne f these apply, he shuld select nne f these. 32 Questin 32 relates t incme that is earned thrugh self-emplyment. This is the net incme Persn 2 earns frm his wn trade r business. Fr example, any net incme (prfit) earned frm gds sld r services prvided t thers cunts as self-emplyment incme. If Persn 2 selects self-emplyment, she shuld describe the kind f wrk. There s n special frmat just a simple descriptin f the wrk is needed. Fr example, if she cleans huses, huse cleaning culd be entered. If she makes jewelry, jewelry making culd be entered. If she wrks n cnstructin prjects, cnstructin culd be entered. T enter the net incme frm self-emplyment, she shuld enter an amunt that includes the net incme r net lss frm self-emplyment. Net incme grss incme frm any trade r business minus allwable deductins fr that trade r business. Allwable deductins include expenses paid t perate the business r participate in the trade, including: Car and truck expenses (fr travel during the wrk day, nt cmmuting) Depreciatin Emplyee wages and fringe benefits Prperty, liability, r business interruptin insurance Interest n lans fr yur business (including mrtgage interest paid t banks) Legal and prfessinal services Rent r lease f business prperty and utilities Cmmissins, taxes, licenses, and fees Advertising Cntract labr Repairs and maintenance This incme shuld be reprted and prf f the incme shuld be included when the packet is returned. This can include pay stubs, tax frms (such as the Schedule SE, Schedule C r Schedule F), r any ther type f prf f the amunts received and hw ften they are received. Page 9 f 19

10 33 Questin 33 shuld include incme nt included in the current jb sectin f the renewal, but shuld nt include child supprt, Veteran s payments r Supplemental Security Incme (SSI). If there is n incme ther than incme already prvided in the current jb sectin Persn 2 shuld select nne. Otherwise, Persn 2 shuld tell us hw much and hw the fllwing is received if applicable: Unemplyment Unemplyment cmpensatin includes any amunt received under an unemplyment cmpensatin law f the United States r a state. Persn 2 must include unemplyment benefits (including frm an emplyer r unin) as incme. Pensins A pensin is a payment r series f payments made t a persn after he retires frm wrk. Generally, the amunt f the incme frm a pensin accunt distributin depends n the type f pensin accunt, hw much was cntributed t the pensin accunt, and whether the amunts cntributed were already taxed. Persn 2 des nt have t include a qualified distributin frm a designated Rth accunt as incme. Scial Security These are the amunt a persn gets frm Scial Security disability, retirement (including railrad retirement (RRB)), r survivr s benefits each mnth. Enter the full amunt befre any deductins, like Medicare premiums, incme tax withhlding, verpayments, child supprt, r alimny. Dn t enter Supplemental Security Incme (SSI) benefits. Retirement Accunts A retirement benefit is a payment r series f payments made t a persn after he r she retires frm wrk. Generally, the amunt f the incme frm a retirement accunt distributin depends n the type f retirement accunt, hw much was cntributed t the retirement accunt, and whether the amunts cntributed were already taxed. Persn 2 des nt have t include a qualified distributin frm a designated Rth accunt as incme. Alimny received Alimny received is mney a persn gets frm a spuse she n lnger lives with, r a frmer spuse, if paid as part f a divrce agreement, separatin agreement, r curt rder. Payments designated in the agreement r rdered as child supprt r as a nn-taxable prperty settlement aren t alimny. Net Farming/fishing If this was already prvided in the renewal packet as self-emplyment incme, it shuld nt be listed again) If Persn 2 has incme frm farming r fishing, he can enter it as farming r fishing incme r self-emplyment incme, but he shuld nly enter it nce. A persn is in the business f farming if he cultivates, perates, r Page 10 f 19

11 manages a farm fr prfit, either as wner r tenant. A farm can include livestck, dairy, pultry, fish, r fruit. It can als include plantatins, ranches, ranges, and rchards. Fishing incme includes amunts received frm catching, taking, harvesting, cultivating, r farming fish, shellfish, crustacean, spnges, seaweeds, r ther aquatic frms f animal r vegetable life, as well as mney frm patrnage dividends and fuel tax credits and refunds. Net rental/ryalty If this was already prvided in the renewal packet as self-emplyment incme, it shuld nt be listed again) Rental incme is the amunt smene pays t use a persn s prperty after prperty expenses are subtracted. Ryalty incme includes any payments received frm a patent, cpyright, r sme ther natural resurce wned. Other incme Any incme received nt already prvided n the renewal frm can be included here. Persn 2 des nt need t prvide incme frm child supprt, Veteran s payments r Supplemental Security Incme (SSI). Other incme might include a ne-time payment received this mnth, such as a bnus r severance. Please prvide the amunt and hw ften the Other incme is received. If it s a ne-time payment be sure t say netime payment). Other incme may als include jury duty pay. If Persn 2 is being paid fr jury duty service, enter hw much he is getting, including reimbursement fr transprtatin. If the mney frm jury duty ges straight t Persn 2 s emplyer, dn t enter it here. Other incme may include Curt awards. If Persn 2 was invlved in and gt mney frm a lawsuit, the mney may be taxable. Examples f mney frm lawsuits that are isn t taxable are amunts awarded fr persnal physical injury r sickness and an amunt received as cmpensatin fr damages t the persn s prperty if the payment is less than the amunt paid fr the prperty. Payments t cmpensate a persn fr lst wages r punitive damages awards are examples f taxable curt awards. If ther incme is selected by a member f the clergy r a religius rder he shuld exclude the same incme excluded n the federal incme tax return. Other incme may include cash supprt, ptin if smene wh isn t the persn s parent r yur spuse claims them as a dependent fr taxes, and the tax filer is n renewal. Prvide the amunt f the cash supprt. Fr example, if the tax filer gives the persn $200 per mnth t help pay fr rent r ther living csts, include that amunt here. Dn t include in-kind supprt that the tax filer prvides, fr example, the value f rm and bard, r clthes purchased by the tax filer. Only enter cash supprt if the persn is a tax dependent f smene ther than a parent r spuse. Other incme may als include gambling, prizes, r awards: This includes lttery winnings. It desn t include prizes that aren t taxable, like mst academic schlarships. Page 11 f 19

12 34 There are certain expenses a persn can use t lwer her grss incme. These expenses are like expenses r deductins allwed by the IRS. Persn 2 desn t have t be a tax filer t get these deductins. Persn 2 shuld tell us abut these deductins in questin 34. Deductins already deducted ut f Self-emplyment incme shuld nt be reprted again here. Persn 2 shuld tell us abut the fllwing if applicable: Alimny paid: Persn 2 shuld tell us hw much they pay and hw ften. Student lan interest: The persn shuld tell us hw much they pay and hw ften. Other deductins: They shuld tell us hw much they pay and hw ften. Other deductins include expenses such as educatr expenses fr teachers wh pay fr supplies ut-f-pcket, mving expenses fr mving t live much clser t a jb, cntributins t an individual retirement accunt if the persn desn t have a retirement accunt thrugh a jb, r tuitin csts fr schl if csts are paid ut-fpcket and deducted n the tax return. Prf f deductins may include tax frm frms, curt rders, cancelled checks, etc., and this prf shuld be sent in with the renewal packet. Step 3 This sectin shuld be cmpleted fr any husehld member wh has health care cverage ther than TennCare. 1 If anyne in the husehld has health cverage frm the fllwing: Medicare Prvide the names f any husehld members with this cverage. TRICARE Prvide the names f any husehld members with this cverage. This shuld nt be checked if the husehld member s TRICARE is direct care r Line f Duty. Veterans Administratin health care prgrams Peace Crps Emplyer insurance Prvide the names f any husehld members with this cverage. Prvide the name f health insurance Prvide the plicy number Specify if the cverage is COBRA r a retiree health plan Other. If the persn has cverage ther than thse listed abve list that cverage here. Prvide the names f any husehld members with this cverage Prvide the name f health insurance Prvide the plicy number Specify if the cverage is a limited-benefit plan, like a schl accident plicy 2 If any persn listed n the applicatin is ffered health cverage frm a jb, we need t knw wh is ffered cverage. This includes cverage ffered frm smene else s jb, like a parent r spuse. Example: If a parent is ffered health cverage at their jb, which include family cverage, they shuld say yes t this questin and the child s name shuld Page 12 f 19

13 be prvided in additin t the parent. Step 4 Federal law prhibits discussin f a persn s case with a third party unless there is written cnsent frm, r unless the persn is present and prvides verbal cnsent t the discussin. If the member wants t give smene permissin t: Talk abut this renewal packet and the member s health care with us; See the member s infrmatin; Act n matters related t this packet and the member s cverage (including getting infrmatin abut the renewal packet); and Sign the renewal packet n the member s behalf. The member shuld als cmplete and send the HCFA Authrized Representative Individual fund n ur website at A member can change an authrized representative anytime. Cntact the Tennessee Health Cnnectin at t change an authrized representative. If smene is already the legal representative f the member, it is helpful t prvide that dcumentatin with the renewal packet. Step 5 This sectin explains the member s rights and respnsibilities, such as: The requirement t prvide true answers; The requirement t ntify us f changes within 10 days. Changes shuld be reprted by calling Tennessee Health Cnnectin (It s very imprtant fr the member t ntify us quickly with any address changes); The prhibitin f discriminatin based n race, clr, natinal rigin, sex, age, sexual rientatin, gender identity r disability. If a member believes they have been treated unfairly, the member can call The requirement t sign ver any health insurance r medical payments frm an insurance prvider r ther cmpany, if the persn is reapprved. The requirement t help the Tennessee Bureau f Investigatin, Office f Inspectr General r ther agency investigate TennCare fraud and abuse. The State s right t recup mney frm a persn s estate, when the persn dies, if the State paid fr medical bills r nursing hme care. The prhibitin f letting smene else use a member s TennCare card. The requirement t prvide an SSN, when the persn has an SSN, with the renewal packet. The right fr TennCare t pursue medical supprt frm a spuse r parent. This sectin asks fr the name f any persn listed n the renewal that is currently incarcerated. If a persn is incarcerated is des nt mean the persn is nt eligible fr TennCare due t incarceratin. The persn may still be able t keep TennCare when they meet ther eligibility requirements. It might impact the persn s inclusin in the husehld size fr ther member being renewed. Page 13 f 19

14 This sectin asks if there is a parent living utside the hme fr any children listed n the applicatin. This sectin prvides ntice f appeal rights. If a persn believes a decisin abut TennCare r CverKids cverage is wrng the persn can file an appeal with Tennessee Health Cnnectin at Mst imprtantly, the persn cmpleting Step 1, legal representative r authrized representative must sign the packet. If there is n signature, TennCare will send a letter requesting a signature befre the renewal packet is be prcessed. Step 6 All dcuments which shuld include the Renewal Packet and prf, alng with Appendix A and/r B (if cmpleted), must be returned t TennCare by the due date in the member s Renewal Packet letter. The letter ID (in the upper left hand crner) is TN 401. Tennessee Health Cnnectin P.O. Bx Nashville, TN (Nte fr DHS: Packets received by DHS MUST be date stamped the day received and faxed t ) The renewal packet must be sent t TennCare within 40 days. If the renewal packet is nt sent within 40 days the member may lse TennCare. Sending dcumentatin r prf we need t decide if yu can keep TennCare may help us prcess the renewal faster. If smene needs help in anther language, call and tell TennCare the language. If smene has a hearing r speech prblem and use a TTY, the persn may call , then dial and chse ptin 4. Appendix A Appendix A shuld nly be used fr members wh have TennCare/CverKids nw and want t keep cverage. Persn 1 answered yes t at least ne f the questins 9-13; Persn 2 (r thers if mre than ne persn has TennCare) answered yes t at least ne f the questins Member is used thrughut the instructins belw as a reminder that nly a persn that has TennCare/CverKids nw can use Appendix A. It cannt be used fr smene wh des nt have TennCare/CverKids nw. Members shuld answer questins in Appendix A if any f the fllwing apply: The member lives in a medical facility r nursing hme, r needs nursing hme care in a nursing hme r at hme; Additinal Resurces Available Members already in the CHOICES prgram that need help with the renewal packet shuld cntact the TennCare health plan (MCO) Care Crdinatr. If the persn des nt knw wh that is r hw t reach them, the Page 14 f 19

15 persn can call the MCO. The number is n the back f the TennCare card. The persn shuld say they want t talk t their CHOICES Care Crdinatr fr help with the TennCare Renewal Packet. If the member lives in a nursing hme, but is nt currently in CHOICES the persn shuld call the lcal Area Agency n Aging and Disability (AAAD) at Ask the AAAD fr help with the TennCare Renewal Packet. The persn can als ask the nursing hme fr help with the renewal packet. If the member is nt in a nursing hme, but needs nursing hme care in a nursing hme r at hme (HCBS), cntact the lcal Area Agency n Aging and Disability (AAAD) at The persn shuld ask fr help with the TennCare Renewal Packet and say they want t apply fr nursing hme care. If the persn is getting HCBS in a PACE r needs HCBS in a PACE, cntact the PACE case manager directly r call PACE at PACE stands fr Prgram fr All- Inclusive Care. PACE is a cmmunity based adult day care prgram whse purpse is t serve the frail elderly residents f Hamiltn Cunty. If the persn is getting HCBS thrugh the Cmprehensive Aggregate Cap (CAC), Statewide r Self-Determinatin waivers fr peple with intellectual disabilities call the ISC r, if yu re in the Self-Determinatin waiver, call yur case manager with the Department f Intellectual and Develpmental Disabilities (DIDD). Or yu can call DIDD at the number belw: If west TN call If in middle TN call If in east TN call If the persn needs HCBS in a waiver fr peple with intellectual disabilities, but is nt currently getting the care nw, call the Department f Intellectual and Develpmental Disabilities (DIDD). If in west TN call If in middle TN call If in east TN call If the persn lives in an ICF/IID, the persn Page 15 f 19

16 The member has Medicare and wants help with Medicare cst sharing (Medicare cpays and deductibles). can ask the ICF/IID t help with the TennCare Renewal Packet. Call the State Health Insurance Assistance Prgram (SHIP) at Tell them yu need help with yur TennCare Renewal Packet, and that yu want t get help r keep help with Medicare cst sharing (QMB r SLMB). The member needs hspice care. Call yur TennCare health plan (MCO). The number is n the back f yur TennCare card. Tell them yu need help with yur TennCare Renewal Packet and yu re getting r need hspice care. The member has received SSI and Scial Security in the same mnth at least since 1977, and still receives Scial Security (Cmplete Appendix A) The member is under age 21 r the persn is pregnant, and the member (r smene in the hme) has medical bills (paid r unpaid) in the last three mnths. If the member answers yes t this questin and has nt answered yes t ther questins in Appendix A, nly Part 1 and Part 5 f Appendix A shuld be cmpleted. The member is getting Scial Security payments (Cmplete Appendix A) (Cmplete Appendix A) Part 1 The name and SSN f the member that needs t cmplete Appendix A shuld be prvided here. If additinal members need t cmplete Appendix A, a cpy shuld be made and cmpleted fr each persn. Part 2 The member shuld answer yes r n t the fllwing: If they qualify fr care in a nursing hme, but want care at hme; If they qualify fr care in an Intermediate Care Facility fr Individuals with Intellectual Disabilities (ICF/IID), but want care at hme instead. Tell us if the persn has an intellectual disability (IQ f 70 r belw) that started befre age 18. If the member has spuse that desn t live in the hme, tell TennCare the name and why the persn des nt live in the hme. If the member is currently getting care in a nursing hme. Page 16 f 19

17 If s, the name f the nursing hme and the date the member started getting nursing hme care. Part 3 The member shuld answer yes r n t the fllwing: If the member is getting a Scial Security check nw and gt a Scial Security check in If the member lst Medicare after ging back t wrk because they started making mney ver the Scial Security incme limit. The member applying, her spuse, adult disabled child, r parent in the hme shuld tell us abut any f the fllwing types f incme being received: Mney frm friends r relatives Child Supprt Payments Unemplyment Payments frm anther state Veteran s Benefits Wrker s Cmpensatin Interest/Dividends/Ryalties A persn might get this type f incme have a checking accunt, savings accunt, CDs, etc. Rental Incme SSI. The member des nt need t prvide prf f SSI incme. TennCare can get that prf. Other. The member shuld tell us abut ther types f incme received, examples include (but are nt limited t): Alimny Payments Pensin Severance The member shuld tell us: Wh gets the incme; The type f incme; Hw much; Wh pays; and The phne number Part 4 The member shuld tell TennCare abut any payments made fr child care, r fr care f an adult that is disabled. Prf, signed by the persn that gives the care, shuld be prvided with the renewal packet. The prf shuld say hw much is paid and hw ften. The member shuld tell TennCare: Wh gets the care; Wh pays fr the care; The cst f the care; Hw ften the care is paid fr; and The name and phne number f the persn giving the care. Page 17 f 19

18 The member shuld als tell TennCare abut expenses and prvide prf shwing hw much the member pays. Examples f expenses include: Curt Ordered Child Supprt Payments; Legally Obligated Alimny; and Blind/Disabled Wrk Expenses. Part 5 The member shuld cmplete Part 5 fr resurces wned by peple in the husehld. The member shuld tell us hw much the resurce is wrth, any amunt still wed, and shuld prvide prf f the resurce. Examples f prf are listed n the renewal packet with each resurce listed. If the member wns a resurce nt specifically listed n the packet, it shuld be listed as Other. Other resurces nt listed in the renewal packet may include (but are nt limited t): Part 6 Farm Equipment; Livestck; and Equipment used fr self-emplyment. The member shuld cmplete Part 6 if the member receives nursing hme care, wants t receive nursing hme care in a nursing hme, r wants t receive nursing hme care at hme (HCBS). The member shuld tell TennCare abut any resurces, things the persn wned, that have been given t smene else in the past 60 mnths (5 years). The member shuld als tell TennCare abut anyne in the husehld that has received a lump sum f mney in the past 12 mnths (1 year). The member shuld include hw much was received, where the mney came frm and shuld send prf. Types f resurces include the types f resurces in Part 5 (but are nt limited t): Prperty Cars and Trucks Mtrcycles and Bats RVs and Campers Trusts Savings Certificates r CDs Burial Cntracts Cemetery Lts Types f lump sum payments include (but are nt limited t): Insurance Payment Lttery Winnings Back Payment f Scial Security Appendix B Appendix B shuld be cmpleted if the TennCare member r a family member is American Indian r Alaska Native and wants t get the mst help pssible. American Indians and Alaska Natives can Page 18 f 19

19 get services frm the Indian Health Services, tribal health prgrams, r urban Indian health prgrams. They als may nt have t pay cst sharing and may get special mnthly enrllment perids. Cpies can be made f Appendix B if mre peple need t be included. Appendix B shuld be included when the renewal packet is returned. All dcuments which shuld include the Renewal Packet and prf, alng with Appendix A and/r B (if cmpleted), must be returned t TennCare by the due date in the member s Renewal Packet letter. The letter ID (in the upper left hand crner) is TN 401. There are 2 ways t send us the dcuments: By Mail: Tennessee Health Cnnectin P.O. Bx Nashville, TN By Fax: Page 19 f 19