Renewal Packet Instructions

Each year, we must see if you qualify for coverage. We will send you a Renewal Packet. It will tell you everything we know about your household. We need you to check the facts we have listed and tell us about any changes that happened in the last year.

Do you need help with completing the Renewal Packet? The instructions below can help you. Or download the Renewal Packet Instructions in English or in Spanish.

Do you need to report changes or send information to TennCare? This page tells you how to send us proof or information we need from you.

• How to Report Changes or Send Information to TennCare
• Cómo reportar cambios o enviar información a TennCare

This Instruction Packet is meant to help you with completing the Renewal Packet. Each Renewal Packet has a bar-code for the household. If you need a copy of the Renewal Packet, call TennCare Connect at 855-259-0701 to request a reprint.

These instructions are written as if the head of household is filling out the Renewal Packet. If you are filling the Renewal Packet out for the head of household, you should fill it out from that person’s point of view.

The Renewal Packet will show questions based on the details we have about you and your household. You may not see all of the questions below on your Renewal Packet if we don’t have those details on file for you or your household.

Remember to print your name, date of birth, and your case number on any proof you send in with the Renewal Packet.

You can get help making copies of any document we request at any Department of Human Services (DHS) office.

What if you need help in person with your renewal packet?

• Your local Department of Human Services can help you. To find your local office, go to https://tn.gov/humanservices and click “Office Locations” at the bottom of the page or call 866-311-4287.
• If you’re getting care at a local community mental health center, they can also help you. Their office are listed at https://www.tamho.org/#services.
• If you have a disability, someone can even come to your house to help you apply for TennCare. Just call your local Area Agency on Aging and Disability (AAAD) at 866-836-6678.

This section lists information about you and your household. Review the information for your household.

Do the people listed below still live together?

This section lists the individuals we have on file as living in your household. This is everyone we know of in your household. It also lists your home address and mailing address. Please review the information of each person listed. If you need more space, you can attach a sheet of paper. Remember to write your name and case number on every page you send us.

If you need to add a person to your household who wants to apply, use the Appendix A attachment.

Your household may include the following people:

• You, the head of household (the person who received the Renewal Packet in the mail)
• Your spouse, if you have one
• Your children (or stepchildren) under age 21 if they live with you
• Anyone listed on your tax return, or anyone listed on a tax return on which you are included, even if they don’t live with you
• Anyone else under age 19 who you take care of and who lives with you

Children Under 21 also include:

• Parent (or stepparent) who live with you
• Sibling (or stepsibling) who live with you
• Your children (or stepchildren) under 21 who live with you
• Anyone you include on your tax return, even if they don’t live with you

You DON’T have to include the following people:

• Your parents who live with you, but file their own tax return (if you’re over age 21)
• Other adult relatives who live with you but file their own tax return

If we have a Social Security Number (SSN), the SSN field will read “On File”. If we are missing a SSN, that field will be blank. If the SSN field is blank next to anyone’s name, write in their SSN.

You don’t need to enter a Social Security Number (SSN) for family members who don’t want health coverage. We’ll keep all the information you provide private and secure as required by law. We’ll use personal information only to see if you and your household qualify for coverage.

Tell us about the relationships between the people in your household. This helps us understand who lives with you. It also helps us decide the kind of coverage you may qualify for. Enter the relationship in the space provided. Relationships could be mother, father, brother, sister, children, stepchildren, grandmother, grandfather, aunt, and uncle.

If Hispanic/Latino, check the box to tell us your ethnicity (Check all that apply).

Tell us about your ethnicity. It will not affect your eligibility decision.

Check the box to tell us your race (Check all that apply).

Tell us about your race. It will not affect your eligibility decision.

Are there other people living with you that are not listed above?

If you would like to apply for coverage for anyone in your household, use Appendix A to tell us more about them.

If you have people living in your household that are not listed and not applying, we still need to know. Tell us in the space provided:

• Their full name
• Date of Birth
• Gender
• Relationship

Remember, if you need more space, please attach a separate sheet of paper.

If any of the people you add want to apply to Katie Beckett, they must go online to tenncareconnect.tn.gov.

Are you a US citizen or a US national? Has citizenship or immigration status changed for you or anyone in your household since last year?

We need to know if you or anyone in your household’s immigration status has changed. If it hasn’t changed, check “No”. If anyone in your household now has a different immigration status, tell us their new status, and the immigration document number. You may need to send us proof of the new immigration status. You do not need to tell us the immigration status for family members who don’t need health coverage.

Tell us if you are a US citizen. If you are not a US citizen or a US national, do you have an eligible immigration status? Tell us “Yes” or “No”. Also tell us:

• Immigration status
• Date you gained the status
• Date you entered the US
• Alien or I-94 number
• Card number or passport number
• SEVIS ID or expiration date (optional)
• Other (category code or country of issuance)

Have you lived in the US since 1996? Tell us “Yes” or “No”.

Are you or your spouse or parent, a veteran or an active duty member of the US military? Tell us “Yes” or “No”.

Are the household address(es) and phone number(s) shown below correct?

Review and confirm your home address and mailing address that we have listed. If you have moved or your mailing address has changed, tell us your new home address and/or mailing address in the space provided.

Is everyone in the household a Tennessee Resident? Are you temporarily living out of state?

Members must be a Tennessee resident to be eligible for TennCare. Tell us if you or anyone in your household is not a Tennessee resident. Or if you or anyone in your household is temporarily living out of state. Tell us if you plan to return to Tennessee and the date.

Is anyone in your household in jail or prison?

Tell us the name of any person listed in the Renewal Packet that’s currently in jail or prison. If a person is in jail or prison, it does not mean they are not eligible for TennCare. The person may be able to keep TennCare if they meet other eligibility rules.

Why do we ask for this information? The person in jail may be counted toward your household size. If a person is in jail or prison, the household size can change for you or other members listed on the Renewal Packet. If no one listed on the renewal packet is in jail or prison, this should be left blank.

What language do you read and write best in?

Tell us if you read and write best in English or Spanish. We will send your notices in the language you choose.

This section asks about tax information for you and your household for the next time you file taxes. Complete the tables provided in the Renewal Packet.

Does anyone in the household plan to file a federal income tax return the next time taxes are due?

Tell us if you plan to file a federal income tax return next year. This may be different from the tax records you already sent the IRS.

Tell us the name of the person(s) filing the tax return. If the person will file jointly, write the name of the spouse and tell us if this person lives outside the home. If the person filing will claim dependents on the tax return, write the name and date of birth for each dependent. If you need more space, you can attach a sheet of paper. Remember to write your name and case number on every page you send us.

Do any dependents live outside of your household?

Tell us the name(s) and birth dates of the dependents.

Will anyone in the household be claimed as a tax dependent by someone else the next time taxes are due?

Tell us the name of the tax dependent, the tax filer’s name and relationship to this person, and if the tax filer and the tax dependent live together.

Do you have tax questions? Visit the IRS website at www.irs.gov.

Do you or anyone in the household pay any expense that can be deducted from your federal income tax return like student loan interest, military moving expenses, or alimony paid?

List the expense. And tell us how much and how often. There are certain expenses you can use to lower your gross income called deductions. These deductions are allowed by the IRS. You don’t have to be a tax filer to get these deductions. These deductions are things like:

• Alimony paid: This is a payment made to a former spouse under a separation agreement. Tell us the date a court ordered alimony.
• Student loan interest: This is interest that a person pays on a qualified student loan payment during the month of application.
• Other deductions such as:
  • Educator expense: for teachers who pay for supplies used in the classroom
  • Moving expense: for a member of the US Armed Force who has a change of station
  • Health Savings Account (HSA) deduction: contributions to a HSA
  • Tuition and fees: tuition costs for school if costs are paid out-of-pocket and deducted on the tax return

  Deductions already taken out of self-employment income should not be reported here.

  Proof of deductions can be things like tax forms, court orders, and cancelled checks. This proof should be sent with the Renewal Packet. Don’t send the original. Send a copy.

  This section asks about employment and income information for all members of your household. This includes earned income and other income. Review the income we have listed for your household and tell us if it is correct.

  Examples of what can be used as proof:

  • Pay stubs
  • Statement from employer
  • Signed statement for tips
  • Federal income tax return (Schedule SE)
  • Business Records
  • Tax forms (1040 or W-2 from the last tax year)
  • Bank statements that clearly show income deposits if other types of proof are not available.

  Don’t send the originals. Send a copy.

  Our records show no one in your home is employed or gets paid for working a job. Does anyone in your household get paid from a job now?

  Tell us if you or anyone in your household gets paid for a job now.

  Review the employment information we found for your household and tell us if it is correct.

  All current employment information we have on file for your household is listed at the beginning of this section. This includes Person, Employer Name, and Monthly Income. Review the information for each person listed.

  This is everyone we know of in your household who is currently employed. If we don’t have income information listed for anyone in your household, we need you to tell us about the income anyone in your household gets. If you need more space, you can attach a sheet of paper. Remember to write your name and case number on every page you send us.

  If all employment information and the amount of monthly income we list is correct, you do not have to list it again in the next question. But we still need you to complete other sections in this Renewal Packet.

  Does anyone get paid for working a job we did not list or do you need to correct the facts?

  Tell us their names in the table provided and attach copies of their pay stubs for the last 8 weeks. If you don’t have 8 weeks of proof, send us what you do have. Include all jobs, even if they’re part time or paid in cash. Send us any pay stubs, tax forms (1040 or W-2), or any other proof of work and income. Tell us if you received tips that are not listed on your pay stubs. If the person is self-employed, attach their tax or business records.

  If we did not list any employment for your household, that means we do not have any employment on record.

  Include the following information about your income:

  • Name: The person who gets this income.
  • Employer: Enter the employer name and address.
  • How much (Wages/tips (before taxes): Enter the amount showing on this person’s pay stubs before taxes are taken out. Include all tip income with the total, even if it’s not reported to the employer.
  • How often:
    • hourly
    • daily
    • weekly
    • twice a month
    • monthly
    • yearly
    • every 2 weeks

    You don’t need to include amounts that an employer takes out of a paycheck for child care, health insurance, or retirement plans that are “not taxable”. Sometimes these are called “pre-tax deductions”.

    The pay stub should list these deductions individually. Don’t include these amounts in the pay listed. The pay stub may list “federal taxable wages,” which deducts pre-tax amounts from gross wages. If federal taxable wages is listed on the pay stub, use it to report pay.

    Review the other income information we have for your household and tell us if it’s correct.

    Tell us if the income listed in the table has ended or changed.

    During the last 30 days did anyone receive any other income?

    Tell us their names, the income type, how much, and how often in the table provided. Other types of income are things like:

    • Unemployment
    • Pensions and Retirement Accounts
    • Social Security
    • Alimony

    Does someone other than a parent (if you are under 18) or spouse help pay for your food OR housing each month?

    You only need to answer this question if you have Social Security income.

    This help can be things like rent or mortgage, property insurance, gas, electric, heating fuel, water, sewer, garbage collection service or property taxes.

    • Does the person who helps pay for this live with you?
    • What do they help you pay for?
    • How much is this expense of the bill?
    • How much do you pay?
    • Number of people in the home?
    • Does everyone living with you get any kind of public assistance?

    Public assistance includes Families First, SSI, Disaster Relief and Emergency Assistance, VA Pension, VA Aid and Attendance, the Refugee Act of 1980 or state or local government assistance programs based on need.

    Have there been any changes in your or your households health coverage? This section should be completed for any member who has health care coverage other than TennCare or CoverKids.

    Has anyone in your family enrolled in other health coverage in the last year?

    If Yes, you must tell us the following:

    • Name of the insurance plan
    • Names of any household members with this coverage
    • Type of Insurance:
      • Medicare
      • TRICARE
      • Veterans Administration Health Care Programs
      • COBRA
      • Peace Corps
      • Retiree health plan
      • Employer Insurance

      Does anyone listed on the Renewal Packet have access to other health coverage through a job?

      Tell us their names. This includes coverage offered from someone else’s job, like a parent or spouse. If a parent is offered health coverage at their job, and it includes family coverage, answer “Yes” to this question. Tell us the child’s name and the parent’s name.

      Did you or anyone in your household lose Medicare because you went back to work and were making more money than your social security limit?

      Tell us their name(s).

      Has anyone in your household had a change in Health Insurance?

      Tell us if anyone in the household had a change or has lost their health insurance.

      The following questions are for you and the people in your household.

      Are you or anyone who lives with you pregnant now OR was pregnant in the last 12 months?

      This person may be eligible for postpartum coverage. Tell us the following:

      • Who is/was pregnant
      • Due date or Pregnancy end date
      • The number of babies expected

      Do you or anyone in your household live with at least one child under the age of 18 (or is the child age 18 and a full time student)? And, are you or anyone in your household the main person taking care of this child?

      Tell us if anyone in your household is the main person caring for a child under 18. Or is caring for an 18-year-old who is still in school full time. If Yes, tell us:

      • The primary caregiver’s name
      • The child(ren)’s name
      • Relationship to the caregiver

      Are you or anyone in your household age 21 or younger and a student?

      Tell us their name and if they are Full Time, Part Time, or Less than Part Time.

      • Full time student means enrollment in at least 12 credit hours per semester.
      • Part time student means enrollment in at least 6 credit hours per semester but less than 12.
      • Less than Part time student means enrollment in less than 6 credit hours per semester.

      Were you or anyone in your household in foster care at age 18 or older and getting Medicaid?

      A person under age 26 may be eligible for TennCare if they were in foster care at 18 and getting Medicaid. Tell us their name.

      Are you or anyone in your household under 65 and who is getting treatment now or do you need treatment for breast or cervical cancer?

      This person may be eligible for TennCare if they need ongoing treatment for breast or cervical cancer.

      Tell us their name if they are currently getting care now or need treatment now for breast or cervical cancer. If the person needing or currently getting treatment for breast or cervical cancer has not been screened for breast or cervical cancer but thinks they might need screening, they should contact the Health Department at www.tn.gov/health/health-program-areas/localdepartments.html.

      Are you or anyone in your household in a medical facility (like a hospital) and have been there at least 30 days? Or are you in a medical facility now and will be there for at least 30 days?

      This person may be eligible for Long-Term Services and Supports. Tell us their name if they have been or will be in a medical facility for at least 30 days. Tell us:

      • When did they go into the medical facility
      • The name of the medical facility. This is optional.
      • Their doctor’s name and phone number. This is optional.

      Long-Term Services and Supports (LTSS) are medical and/or personal care and supportive services for individuals who need help to do daily living activities. These are things like bathing, dressing, eating, transfers and toileting. And it can be activities that are essential to daily living like housework, preparing meals, taking medications, shopping, and managing money. LTSS offers care through a nursing facility or in-home community-based services. For more information, go to www.tn.gov/tenncare/long-term-services-supports.html.

      This part will only be included in your Renewal Packet if you or someone in your household is getting Long Term Services and Support through CHOICES.

      Review the information we have on file in the table provided. If you need a different type of care, fill out the Questions Part 2 section.

      The following questions are for you and the people in your household. If you answered “Yes” to any of these questions, fill out the Resources section.

      Did you or anyone in your household receive Supplemental Security Income, or SSI benefits, in the past but don’t now?

      Tell us their name and when the SSI benefits ended.

      Do you or someone in your household live in a medical facility or nursing home?

      Tell us their name if they live in a medical facility or nursing home. You must also tell us:

      • the name of the medical facility or nursing home
      • when care started

      Do you need nursing home care either in a nursing home or at home?

      A nursing home is a place that provides a room, meals and help with daily living activities. Daily living activities are things like cooking, eating, bathing, toileting and mobility.

      Tell us their name if they need the kind of care provided in a nursing home. This kind of care may be provided at home.

      Would you or someone in your household qualify for care in a nursing home, but want care at home instead?

      You or someone in your household may be eligible to get care and support at home.

      Tell us their name if they need the kind of care provided in a nursing home but want care at home.

      Would you or someone in your household qualify for care in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), but want care at home instead? Does this person have intellectual disabilities (an IQ of 70 or below) that started before age 18?

      Tell us their name if they need the kind of care provided in an ICF/IID but want care at home instead.

      Do you or someone in your household have a spouse (a husband or wife) who doesn’t live in your home too?

      Tell us their name if they have a spouse that doesn’t live in the home. You must also tell us why the person does not live in the home.

      Are you or someone in your household getting Home and Community Based Services (HCBS) in CHOICES or PACE?

      Home and Community Based Services (HCBS) and Program of All-Inclusive Care for the Elderly (PACE) offer in-home care to help individuals who need help with daily living activities.

      If Yes, tell us their name(s).

      Are you or someone in your household getting HCBS through the Comprehensive Aggregate Cap (CAC), Statewide, or Self-Determination waivers for people with intellectual disabilities?

      Comprehensive Aggregate Cap (CAC), Statewide and Self-Determination Waivers offers services to children and adults with intellectual disabilities and children under 6 with developmental delay to support their independence in the community.

      If you or someone in your household gets HCBS through a CAC, Statewide or Self-Determination waiver, tell us their name(s).

      Do you or someone in your household have intellectual and/or other developmental disabilities and want to receive Home and Community Based Services (HCBS and participate in Employment and Community First CHOICES?

      Employment and Community First CHOICES (ECF) provides long-term services and supports for people of all ages who have an intellectual or a developmental disability. The ECF programs help individuals live in the community and not in an institution. For more information, go to www.tn.gov/tenncare/long-term-services-supports/employment-and-community-first-choices.html.

      If Yes, tell us their name(s).

      Do you or someone in your household need hospice care?

      If Yes, tell us their name(s).

      Are you or someone in your household entitled to Medicare and want to get or keep help paying your Medicare Cost Sharing, like QMB or SLMB?

      This is also known as Medicare Saving Plan (MSP). These pay for your Medicare premiums and sometimes your Medicare co-pays and deductibles. If Yes, tell us their name(s).

      Are you or anyone in your household pregnant or under 21?

      If Yes, have you or anyone else in your home gotten care or medicine in the last 3 months and have bills (paid or unpaid) related to that care or medicine? Or have you paid for any medical bills this month (no matter how old they are)? If Yes, list any medical or dental bills for care or medicine in the last 3 months in the table provided. Tell us:

      • Name
      • Where you got car
      • How much is the bill
      • Date of service

      Are you or anyone in your household age 21 or younger and work full time?

      Tell us their name.

      Katie Beckett is only for children under the age of 18 with complex medical needs or disability but don’t qualify for Medicaid because of their parents’ income or resources. If you qualify for Medicaid, you can’t enroll in Katie Beckett. If you don’t qualify for Medicaid, you can apply online at: tenncareconnect.tn.gov.

      For additional resources:

      • If you are getting HCBS and need help with the Renewal Packet, contact your TennCare health plan (MCO) Care Coordinator. Or call the number on the back of your TennCare card.
      • If you are in a nursing home but not in a CHOICES program and need help with the Renewal Packet, ask the nursing home for help. Or call the local Area Agency on Aging and Disability (AAAD) at 866-836-6678.
      • If you are not in a nursing home but need nursing home care in a nursing home or at home and need help with the Renewal Packet, call the local Area Agency on Aging and Disability (AAAD) at 866-836-6678. Tell them you want to apply.
      • If you are getting HCBS in a Program for All-Inclusive Care (PACE) or need HCBS in a PACE, and need help with the Renewal Packet, call the PACE manager. Or call PACE at 423-495-9114. PACE stands for Program for All-Inclusive Care. PACE is a community-based adult day care program whose purpose is to serve the frail elderly residents of Hamilton County.
      • If you are getting HCBS through the Comprehensive Aggregate Cap (CAC) or Statewide and need help with the Renewal Packet, call your Independent Support Coordinator.
      • If you are getting HCBS through the Self-Determination Waiver and need help with the Renewal Packet, call the Department of Disability and Aging (DDA).
        • If you live in west Tennessee, call 866-372-5709.
        • If you live in middle Tennessee, call 800-654-4839.
        • If you live in east Tennessee, call 888-531-9876.
        • If you live in west Tennessee, call 866-372-5709.
        • If you live in middle Tennessee, call 800-654-4839.
        • If you live in east Tennessee, call 888-531-9876.

        This section asks about expenses for your household. This section should only be completed if a question was marked “Yes” in the Question Part 2.

        Do you or anyone in your household pay for child care or care for a disabled household member?

        Tell us about any payments made for child care or for care of an adult who is disabled. You must also tell us:

        • Who gets the care
        • Who pays for the care
        • How much is paid for the care
        • How often payment is made for the care

        Send proof that shows who gives the care and how much you pay. Don’t send the original. Send a copy. Remember to write your name and case number on every page you send us.

        Do you or anyone in your household have expenses for things to help you work because you are blind or disabled? Or, do you owe on medical bills (even if you’ve sent them to us before)?

        Tell us about any impairment-related and blind work expenses anyone in your household pays for. This can be things like medical services, medical devices, and physical therapy which you need to be able to work. You must also tell us:

        • What is the expense
        • Who pays for this expense
        • How much you pay for this expense
        • How often you pay this expense

        Did you answer “Yes” to the question “Are you or anyone in your household pregnant or under age 21?” in the Questions Part 2 section?

        If you answered “Yes”, complete the table provided in the Renewal Packet. List any medical or dental bills for care or medicine you or someone in your household received in the last 3 months. These can be things like doctor’s fees, hospital charges and over the counter medicine. You must also tell us:

        • Where did you get care
        • How much is the bill
        • Date of service

        Resources are things owned by you or a person in your household, such as vehicles, bank accounts and property. This section asks if there have been changes in resources for you or anyone in your household. Only tell us about the resource(s) that changed or are not listed.

        This section should only be completed if a question was marked “Yes” in the Questions Part 2 section. You must send in proof of your resource with the Renewal Packet. Don’t send the original. Send a copy.

        Our records show no one in your home has resources (assets). Does anyone in your household have resources?

        We do not show that you have any resources. Tell us if you have any resources.

        Please review the resources (assets) you have told us about for your household.

        A resource is real or personal property that has cash value. Resources are things like cash, savings, stocks, houses, land, and vehicles. Tell us if you still have the resource and how much it’s currently worth. These are all the resources we know of in your household. If all resource information is correct, tell us the current value.

        Do you or anyone living with you own other resources (assets) not listed above?

        If we don’t have Resource information already listed, tell us about Resources you or anyone in your household gets. Check the Resource Type. You must also tell us:

        • Name of Owner
        • What is the value
        • How much do you owe on it

        If you or anyone in your household owns a resource not specifically listed on the Renewal Packet, it should be listed as Other. Other resources not listed in the Renewal Packet may include (but are not limited to):

        • Farm Equipment
        • Livestock
        • Equipment used for self-employment

        In the last 60 months (5 years), has anyone in your household sold, given away or transferred ownership of any of the things you own (listed above in the Resources Section) for less than its worth?

        Tell us if you or anyone in your household has sold, given away or transferred ownership of any of the following:

        Cash and bank accounts

        Mutual funds, stocks, bonds

        Savings or credit union accounts

        401(k), IRA or Keogh accounts

        Christmas Club accounts

        Loan (money that is owed to you)

        Irrevocable Burial Contract

        Saving certificates or CDs

        Tax shelter accounts

        Motorcycle or boat

        Property or land

        Car, truck or motor vehicle

        Life Insurance Policy

        Other (if marked)

        Complete the table provided in the Renewal Packet. You must tell us:

        • What did you sell, trade, or give away
        • Who owned this resource
        • Who did you sell, trade, or give away this resource to
        • Why did you sell, trade, or give away this resource
        • What date did you sell, trade, or give away this resource
        • What was it worth
        • How much money was received when the resource was sold, traded, or given away

        If you need more space, you can attach a sheet of paper. Send proof that shows what was sold or given away. Don’t send us the original. Send a copy. Remember to write your name and case number on every page you send us.

        In the last 12 months (1 year) has anyone in your household gotten a lump sum of money?

        Tell us if anyone in the household got a lump sum of money. This could be things like an insurance settlement, back pay for Social Security or a lottery prize. You must also tell us:

        • Name of person
        • How much did this person get
        • Where did it come from
        • When did you get this lump sum

        The kind of proof you can send us are bank records or award letters that show how much you got. Don’t send us the original. Send a copy.
        

        This section tells you how to get help with your Renewal Packet.

        An Authorized Representative is a trusted person who, with your consent (OK), will:

        • Talk about this Renewal Packet and your household health care with us
        • See your information
        • Act for you on matters related to this packet and your coverage (including getting information about your Renewal Packet)
        • Sign an Application for all members in your household
        • Complete and submit a Renewal Packet for your household
        • Receive all notices, insurance cards, and other communications about the application, appointments, renewals or eligibility for your household

        Federal law prohibits discussion of a person’s case with a third party unless there is written consent from the head of household, or unless the person is present and provides verbal consent.
        

        If you have an authorized representative, their information will be provided on the Renewal Packet. Review the information.
        

        Do you want the rights and responsibilities for your authorized representative to change?
        

        If Yes, select what rights and responsibilities you want them to have. You may also choose to end the rights and responsibilities of your authorized representative.

        Do you have an authorized representative who can talk to us about your Renewal Packet on your behalf?
        

        Your Authorized Representative can be an individual or an organization. Information shared by and with your representative may be shared with others. Not everyone has to follow the same privacy rules. They will continue to have these rights until you tell us you want to change them. Complete the table provided in the Renewal Packet.

        If the representative helping you is part of an organization, such as a hospital, a doctor, or a nursing home, the representative must complete the table provided in the Renewal Packet. Tell us:

        • Organization name (if it applies)
        • ID number (if it applies)
        • Signature
        • Date (if it applies)

        If you or someone in the Renewal Packet already has a legally appointed representative (a guardian, custodian or power of attorney), send us proof with the packet.
        

        This section tells you what your rights and responsibilities are as a TennCare or CoverKids member. Be sure to read and understand these rights and responsibilities. If you have questions, call us at 855-259-0701.

        Renewal for Coverage in Future Years

        Usually, we must renew your eligibility each year to see if you and your household still qualify. To make it easier to renew your coverage, we can use federal sources, like information from your tax returns.

        Tell us if you give us your OK to renew your coverage using tax data. You can give us your OK from 1 year or up to 5 years (but no more than 5 years).

        It’s OK if you don’t want to give us your OK to use tax data. We’ll still try to see if you are eligible using other sources.

        We will try to verify your household’s resources using a credit reporting agency to make it easier for you. Do you give us your OK to check your household’s resources with a credit reporting agency?

        Tell us if you give us your OK to use your household’s information to verify resources using a credit reporting agency.

        My right to appeal

        This section also tells you about your right to file an appeal. If you think a decision we made is wrong, this tells you how to file an appeal.

        You (or a legal representative or authorized representative) must sign the Renewal Packet. Sign in the box that says “Signature”. Write your full name and date.

        What if the Renewal Packet is sent to us but it is not signed? We’ll send a letter asking for a signature before we can review your Renewal Packet.

        Remember to send us your completed Renewal Packet and proof!

        Be sure to send the Renewal Packet and proof (such as proof of income) and Appendix A and/or B (if completed). And be sure to send it to us on time. It must be sent to TennCare by the due date listed in the letter that came with the Renewal Packet.

        There are 3 ways to renew your coverage. You only need to choose one:

        • Using TennCare Connect to renew online at tn.gov/tenncare . Log into your account and choose “Renew my Coverage”. Haven’t created an online account yet or downloaded the app? Go to tn.gov/tenncare to find out more.
        • Over the phone by calling 855-259-0701.
        • Fill out, sign, and send us this Renewal Packet. There are 2 ways to send your pages to us.
          • By Mail: TennCare Connect
            P.O. Box 305240
            Nashville, TN 37230-5240
          • By Fax: 855-315-0669

          What if the Renewal Packet is not returned by the due date? You and your household may lose health coverage with us. Sending the proof we need to decide if you can keep coverage may help us review the Renewal Packet faster.

          Does someone need help in another language? Call 855-259-0701 and tell us the language. If someone has a hearing or speech problem and uses a TTY, call 800-848-0298, then dial 855-259-0701 and choose option 4.

          TennCare is a voter registration agency. You can choose to apply today to register to vote.

          If you or anyone in your household would like to register to vote, TennCare will send you a voter registration form in the mail.

          You can also apply to register to vote online at www.sos.tn.gov/elections.

          You do not have to be registered to vote to be enrolled in our program. Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by TennCare.

          If you need help completing the voter registration form, call us at TennCare Connect. You can also fill out the application form in private.

          If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Division of Election:

          By MAIL: Division of Election

          312 Rosa L Parks Avenue 7 th Floor,

          Snodgrass Tower Nashville, TN 37243-1102

          By PHONE: 1-877-850-4959

          Appendix A should be completed if you want to apply for someone in your household who is not getting TennCare, CoverKids, or MSP now. If this person already has coverage with us, you don’t need to fill out Appendix A.

          Copies can be made of Appendix A if more people need to be added.

          Remember, they can’t use Appendix A to apply for Katie Beckett. If any of the people you add want to apply Katie Beckett, they must go online to tenncareconnect.tn.gov.

          The new person should complete the table provided in Appendix A, which includes the following

          • First name, middle name, last name & suffix (Jr., Sr., III)
          • Date of birth
          • Sex (Male/Female)
          • SSN

          The new person’s Social Security Number (SSN) should be provided to help us determine the persons eligibility more quickly. There are some reasons you do not have to provide a SSN, but if the person you want to add has an SSN, that information should be provided.

          If you want help getting a SSN, call 800-772-1213 or visit www.SSA.gov. TTY users should call 800-325-0778.

          Are you age 22 or younger and a student?

          Tell us if the new person is age 22 or younger and is a student. Tell us if their school enrollment status is Full Time, Part Time or less than Part Time.

          Were you in foster care at age 18 or older and getting Medicaid?

          Tell us if the new person was in foster care at age 18 or older while they were getting Medicaid.

          Are you under age 65 and getting treatment now or do you need treatment for breast or cervical cancer?

          Tell us if the new person is under 65 and needs or is currently getting treatment for breast or cervical cancer.

          If the new person has not been screened for breast or cervical cancer but thinks they might need screening, they should contact the Health Department at www.tn.gov/health/health-program-areas/localdepartments.html.

          Are you a US citizen or a US national?

          Tell us if the new person is a US citizen or a US national. Eligible immigration status means the new member has a status that allows you to be considered for health coverage.

          If they have eligible immigration status, you must also tell us:

          • Their new status
          • Date they gained the status
          • Date they entered the US
          • Alien or I-94 number
          • Card number or passport number
          • SEVIS ID
          • Other (category code or country or issuance)
          • If they have lived in the US since 1996
          • If they or their spouse or parent is a veteran or an active duty member of the US military

          The new member should provide all applicable numbers/IDs to ensure their status can be confirmed for their eligible immigration status.

          Examples of an eligible immigration status are:

          • Refugees
          • Asylee
          • Cuban or Haitian entrants
          • Non-citizens who are lawfully permanent residents for 5 years or more

          If Hispanic/Latino, check the box to tell us your ethnicity (Check all that apply).

          Tell us the ethnicity of the new person. You can select one or more from the list provided in the Renewal Packet.

          Check the box to tell us your race (Check all that apply).

          Tell us the race of the new person. You can select one or more from the list provided in the Renewal Packet.

          Appendix B should be completed if the TennCare member or a family member is an American Indian or Alaska Native and wants coverage.

          American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods.
          

          Copies can be made of Appendix B if more people need to be added. Appendix B should be returned with the Renewal Packet.
          

          What can you use as proof?
          

          These are things that verify you are an American Indian or Alaskan Native. These are things like:

          • Tribal identity cards
          • Certificates of Indian birth
          • Other documentation from a tribe, the Indian Health Services (IHS), or the Bureau of Indian Affairs (BIA)

          Tell us the First, Middle and Last name of the person in your household who is an American Indian or Alaskan Native.
          

          Member of a federally recognized tribe?
          

          Tell us if this person is a member of a federally recognized tribe. If Yes, you must tell us the Tribe name and the state the tribe is located in.

          Has this person ever gotten a service from the Indian Health Services, a tribal health program or urban Indian health program, or through a referral from one of these programs?
          

          Tell us if you or anyone in your household has gotten services from a Indian Health Services, a tribal program, or urban Indian health program. Or if you or anyone in your household got a referral from one of these programs.

          If No, is this person eligible to get services from the Indian Health Services, Tribal health programs, urban Indian health program, or through a referral from one of these programs? Tell us Yes or No.
          

          Certain money received may not be counted for Medicaid or CoverKids. List any income (amount and how often) reported on your applications that includes money from these sources.
          

          Tell us how much and how often you get payments from things like natural resources, royalties, farming, or for selling things.

          REMEMBER: All documents must be returned to TennCare by the due date listed in the Renewal Packet letter. The letter ID (in the upper right corner) is TN 401. These documents should include the Renewal Packet and proof, along with Appendix A and/or Appendix B (if completed).
          

          Be sure to keep the originals for your records. Send us a copy.
          

          See the “How to Report Changes or Send Information to TennCare” page at the end of the Renewal Packet.