Tennessee Medicaid (TennCare CHOICES) Long-Term Care Application Packet

TENNESSEE MEDICAID (TENNCARE CHOICES) LONG-TERM CARE APPLICATION PACKET

TABLE OF CONTENTS

1. Cover Letter to Bureau of TennCare
2. Applicant and Spouse Information
3. Program Selection — TennCare CHOICES
4. Financial Eligibility Snapshot
5. Document Checklist
6. Asset Inventory and Exempt Resource Worksheet
7. Income Worksheet and Income-Cap Analysis
8. Qualified Income Trust (Miller Trust) Verification
9. 60-Month Look-Back Disclosure of Transfers
10. Spousal Impoverishment Protections
11. Primary Residence Treatment
12. Authorized Representative Designation
13. Applicant Affidavit and Signature
14. Tennessee Practice Notes
15. Sources and References

1. COVER LETTER TO BUREAU OF TENNCARE

[DATE]

Bureau of TennCare
Long-Term Services and Supports / Eligibility
310 Great Circle Road
Nashville, TN 37243

Re: Application for TennCare CHOICES Long-Term Services and Supports
Applicant: [APPLICANT FULL LEGAL NAME]
SSN (last four): [XXX-XX-####]
Date of Birth: [__/__/____]

Dear TennCare Eligibility Specialist:

Enclosed please find the application of [APPLICANT NAME] for TennCare CHOICES Long-Term Services and Supports, together with the supporting documentation enumerated in Section 5 of this packet. The applicant seeks eligibility under Group [1 — Nursing Facility / 2 — HCBS / 3 — At-Risk] of the CHOICES program effective [__/__/____].

The applicant is [under / over] the Special Income Limit and [has / has not] funded a Qualified Income Trust ("Miller Trust") consistent with 42 U.S.C. § 1396p(d)(4)(B). Verification appears at Section 8.

Please direct correspondence to the undersigned authorized representative.

Respectfully,

[________________________________]

[AUTHORIZED REPRESENTATIVE NAME]

[ADDRESS / PHONE / EMAIL]

2. APPLICANT AND SPOUSE INFORMATION

3. PROGRAM SELECTION — TENNCARE CHOICES

☐ CHOICES Group 1 — Nursing Facility care (medically eligible; resides in licensed NF).

☐ CHOICES Group 2 — Home and Community-Based Services (HCBS) for adults age 65+ or 21+ with physical disability who meet NF level of care.

☐ CHOICES Group 3 — "At-Risk" demonstration category for individuals who do not yet meet NF level of care but are at risk of institutionalization (limited HCBS).

☐ TennCare Standard / Institutional Medicaid (non-CHOICES institutional category, where applicable).

4. FINANCIAL ELIGIBILITY SNAPSHOT

5. DOCUMENT CHECKLIST

☐ TennCare paper application or TennCare Connect online submission confirmation.

☐ Pre-Admission Evaluation (PAE) approval letter (CHOICES Groups 1 and 2).

☐ Birth certificate or U.S. passport for applicant (citizenship).

☐ Social Security card for applicant and spouse.

☐ Medicare card and Part D / supplement policy for applicant.

☐ Photo identification (Tennessee driver license or state ID).

☐ Proof of Tennessee residency (utility bill, lease, deed).

☐ Marriage certificate (if married); divorce decree or death certificate (if applicable).

☐ Five (5) years of monthly bank statements for ALL accounts (checking, savings, CDs, money market) — applicant and spouse.

☐ Five (5) years of brokerage / IRA / 401(k) / annuity statements.

☐ Life insurance policies — face value, cash surrender value (CSV), and current declarations.

☐ Burial / funeral pre-need contracts (irrevocable preferred).

☐ Deeds for all real property — primary residence and any other parcels.

☐ Vehicle titles (one vehicle is generally exempt regardless of value).

☐ Most recent two (2) federal income tax returns.

☐ Award letters: Social Security, SSDI, VA, pension, RMD distributions.

☐ Long-term care insurance policy and benefit history.

☐ Trust instruments — revocable, irrevocable, special needs, Miller Trust.

☐ Power of attorney (durable / financial) and health care advance directive.

☐ Conservatorship / guardianship orders (if applicable).

☐ Documentation of any transfers, gifts, or sales below fair market value during the prior 60 months.

☐ Qualified Income Trust agreement, EIN, bank-account opening documents, and first deposit (if income exceeds the cap).

6. ASSET INVENTORY AND EXEMPT RESOURCE WORKSHEET

Total Countable Assets (Applicant): $[________]

Total Countable Assets (Community Spouse): $[________]

7. INCOME WORKSHEET AND INCOME-CAP ANALYSIS

Special Income Limit (300% of SSI FBR) — confirm current year: $[________]/mo

☐ Applicant gross income is AT OR BELOW the Special Income Limit. Miller Trust NOT required.

☐ Applicant gross income EXCEEDS the Special Income Limit. A Qualified Income Trust (Miller Trust) IS REQUIRED under 42 U.S.C. § 1396p(d)(4)(B). See Section 8.

8. QUALIFIED INCOME TRUST (MILLER TRUST) VERIFICATION

If income exceeds the Special Income Limit, the applicant must establish a Qualified Income Trust meeting all requirements of 42 U.S.C. § 1396p(d)(4)(B) and Tenn. Comp. R. & Regs. 1240-03-03.

Trust name: [________________________________]

Trustee: [________________________________]

EIN: [__-_______]

Bank / account number (last four): [________________ / ####]

9. 60-MONTH LOOK-BACK DISCLOSURE OF TRANSFERS

Tennessee will examine all uncompensated transfers made during the 60 months immediately preceding application. The transfer-penalty divisor is the Average Daily Cost of NF Care published by the Bureau of TennCare (confirm current rate; $295.87/day for 2026).

Total Uncompensated Value: $[________]

Calculated Penalty Period (days): [Total Uncompensated Value ÷ Current Daily Divisor] = [________] days

☐ No uncompensated transfers occurred during the look-back period.

☐ Transfers fall within a statutory exception (transfer to spouse; disabled child; caregiver-child residing in home for two years; sibling with equity interest; trust for sole benefit of disabled person under 65). Documentation attached.

☐ Hardship waiver requested under 42 U.S.C. § 1396p(c)(2)(D) and TennCare policy. Affidavit attached.

10. SPOUSAL IMPOVERISHMENT PROTECTIONS

☐ Community spouse requests Fair Hearing for higher CSRA based on actual income shortfall.

☐ Community spouse requests increased MMMNA based on documented housing / utility costs above shelter standard.

11. PRIMARY RESIDENCE TREATMENT

The applicant's primary residence is exempt for eligibility purposes if:

• The applicant intends to return home (institutionalized applicant signs Intent-to-Return statement); OR
• A community spouse, dependent child, or qualifying relative resides in the home; AND
• Equity in the home does not exceed the federal cap (CMS-indexed; verify current limit).

TennCare estate-recovery notice: Pursuant to 42 U.S.C. § 1396p(b) and T.C.A. § 71-5-116, TennCare may seek recovery from the probate estate of a deceased Medicaid recipient age 55 or older for nursing facility, HCBS, hospital, and prescription-drug services paid. The home and other assets remaining in the estate at death may be subject to recovery.

12. AUTHORIZED REPRESENTATIVE DESIGNATION

I, [APPLICANT NAME], designate the person named below as my authorized representative for purposes of this TennCare application, including receipt of notices, communications with the Bureau of TennCare, and participation in any administrative hearing.

13. APPLICANT AFFIDAVIT AND SIGNATURE

STATE OF TENNESSEE

COUNTY OF [COUNTY]

I, [APPLICANT NAME], being first duly sworn, depose and state:

1. The information contained in this application packet, including the asset inventory, income worksheet, transfer disclosures, and supporting documents, is true, complete, and correct to the best of my knowledge and belief.

2. I have disclosed every uncompensated transfer of assets made by me or my spouse during the sixty (60) months immediately preceding the date of this application.

3. I understand that knowingly providing false information to obtain Medicaid benefits is a violation of state and federal law and may subject me to criminal prosecution, civil penalties, and recoupment of benefits.

4. I authorize the Bureau of TennCare and its agents to verify the information provided through any source, including financial institutions, employers, the Social Security Administration, the IRS, and asset-verification services.

5. I acknowledge receipt of notice regarding TennCare estate recovery under T.C.A. § 71-5-116.

[________________________________]

[APPLICANT NAME / AUTHORIZED REPRESENTATIVE]

Sworn to and subscribed before me this [____] day of [_______________], 20[____].

[________________________________]

Notary Public, State of Tennessee

(My Commission Expires: [_______________])

14. TENNESSEE PRACTICE NOTES

• Income-cap state. Tennessee uses the 300%-of-SSI Special Income Limit. There is no medically-needy spend-down for institutional or CHOICES eligibility. The Miller Trust (QIT) is the only mechanism to qualify a high-income applicant.
• Penalty divisor. The Bureau of TennCare publishes the Average Daily Cost of NF Care annually. The 2026 daily divisor is $295.87 (monthly $8,846.10); confirm the current figure before computing penalties.
• CHOICES groups. Group 1 covers NF residents; Group 2 covers HCBS recipients age 65+ or 21+ disabled who meet NF level of care; Group 3 is the "At-Risk" demonstration. HCBS recipients are not eligible for institutional Medicaid during a penalty period.
• PAE. A Pre-Admission Evaluation by the applicant's MCO or Area Agency on Aging and Disability is required for clinical eligibility. Allow 30–60 days.
• Estate recovery. TennCare actively pursues estate recovery against the probate estate of decedents 55+. Plan home transfers carefully; consider the caretaker-child and disabled-child exceptions where supported by documentation.
• Annuities. Post-DRA-2005 annuities must name the State as remainder beneficiary up to Medicaid expenditures; otherwise the annuity is treated as a transfer.
• Promissory notes / loans. Must be actuarially sound, non-cancelable, and have equal payments to avoid being treated as transfers.
• Fair hearings. Adverse eligibility decisions may be appealed by requesting a Fair Hearing within the time stated in the notice (generally 40 days for TennCare). Continue benefits during appeal where applicable.
• TennCare Connect. Online applications and renewals are processed through https://tenncareconnect.tn.gov; paper applications can be mailed to the address in Section 1.

15. SOURCES AND REFERENCES

• Bureau of TennCare — https://www.tn.gov/tenncare
• TennCare Connect — https://tenncareconnect.tn.gov
• TennCare CHOICES Long-Term Services and Supports — https://www.tn.gov/tenncare/long-term-services-supports.html
• Bureau of TennCare, "Transfer of Assets and Penalty Periods" — https://www.tn.gov/content/dam/tn/tenncare/documents/TransferOfAssetsAndPenaltyPeriods.pdf
• Tennessee Comp. R. & Regs. Chapter 1240-03-03 (Medicaid eligibility) — https://publications.tnsosfiles.com/rules/1240/1240-03/1240-03-03.pdf
• Tenn. Comp. R. & Regs. 1200-13-14 (Long-Term Services and Supports) — https://publications.tnsosfiles.com/rules/1200/1200-13/1200-13-14.20250801.pdf
• T.C.A. Title 71, Chapter 5 (Medical Assistance) — https://www.capitol.tn.gov
• 42 U.S.C. § 1396p (transfers, trusts, liens, estate recovery) — https://www.govinfo.gov
• Tennessee Commission on Aging and Disability — https://www.tn.gov/aging
• Help4TN — Qualified Income Trust resource — https://www.help4tn.org/senior-services/legal-information/healthcare/qualified-income-trust

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. A Tennessee-licensed elder law or Medicaid planning attorney must review and customize this packet before filing. Eligibility limits, penalty divisors, and federal indexed amounts change annually; verify all figures before submission.