«Important Note: TennCare implemented the Newborn PE (NPE) program on August 18, 2014. In the interest of expediency, we implemented the Newborn PE ...»
Frequently Asked Questions on
Newborn Presumptive Eligibility
UPDATED: June 16, 2016
Important Note: TennCare implemented the Newborn PE (NPE) program on August 18,
2014. In the interest of expediency, we implemented the Newborn PE program without
executing formal agreements with participating hospitals. In the coming months, TennCare will
circulate a Newborn PE agreement, which hospitals must execute to continue to perform
Newborn PE determinations. Additionally, these hospitals must begin using a new interface at TennCare Online Services later this year. However, hospitals that participate in the Hospital PE program and sign a Hospital PE agreement will not need to sign a second agreement for Newborn PE – and they can use the Hospital PE interface for all PE transactions (including those for newborns). To find out more about Hospital PE, visit http://tn.gov/tenncare/section/providers.
Contents Overview of NPE NPE Process Clarifications Newborns Entering DCS Custody NPE Form Explanations Qualified Entities Distinguishing NPE and Existing Programs CoverKids Emergency TennCare Submitting Information to TennCare Overview of NPE
1. What is newborn presumptive eligibility?
The newborn presumptive eligibility (NPE) process allows a qualified entity to quickly enroll eligible newborns (age 12 months or younger) in TennCare. Effective August 18, 2014, a hospital or birthing center acting as a qualified entity can immediately and presumptively enroll eligible newborns in TennCare for a specified period while the parents complete the full TennCare application and await a formal determination.
2. What is the process for applying for NPE?
The NPE process works in the following manner:
The applicant completes TennCare’s one-page NPE Form at a qualified entity and signs and dates the form.
FAQs on Newborn Presumptive Eligibility Page 1 Bureau of TennCare UPDATED: June 16, 2016 A trained employee of the qualified entity shall then compare the applicant’s selfreported household income and household size on the NPE Form to the TennCare income limit (on the back of the form). Based on this comparison of self-reported information to the income table, the employee of the qualified entity shall determine NPE.
The employee shall sign and date the NPE Form and explain the NPE determination to the applicant.
The employee of the qualified entity must also explain the next steps of the process to the
If the employee approves NPE, the employee shall explain to the applicant that he or she must complete a full TennCare application at www.healthcare.gov by the end of the next month. The employee must also explain that if the applicant does not apply by this time, the baby may lose eligibility.
If the employee denies NPE, the employee shall explain that the applicant can also apply at www.healthcare.gov for TennCare and other programs.
Whether approved or denied, the employee shall give the applicant a hard copy of the application form for the federally-facilitated marketplace (FFM).
The employee should also fill out and give to the applicant an NPE Eligibility Notice. A template notice is at located under the Providers tab at www.tn.gov/tenncare Finally, the employee should transmit data for approvals for NPE to TennCare via TennCare Online Services. See FAQ #31 for more information about the submission process.
Employees should submit data only for approvals; employees should not transmit information on cases that they deny (e.g., because the applicant was over the TennCare income limit).
3. When does NPE period start?
If the qualified entity approves a newborn’s NPE application, the newborn’s NPE period begins on the date of the NPE application. For example, an NPE applicant applies on August 22, 2014 for a baby born on August 18, 2014. The NPE period will begin on August 22, 2014 (i.e., the date of the NPE application).
Please note that the effective date for NPE is determined by federal rules. See 42 CFR § 435.1101 (stating that the presumptive period “…begins on the date on which a qualified entity determines that a child is presumptively eligible….”).
4. How long does NPE period last?
If the applicant applies for TennCare through the regular process at healthcare.gov by the end of the following month, then the newborn will remain in the NPE period until the FFM makes a formal TennCare eligibility determination. If the applicant does not apply by the end of the following month, then the newborn’s NPE eligibility period will end at that time.
If the FFM determines that the applicant is ineligible for TennCare, then the applicant’s coverage in TennCare will end on the date of that determination. However, the newborn’s NPE period will remain intact up until that day. Please also note that some such newborns will be eligible for CoverKids and will transition to that program. Others may be eligible for coverage in qualified health plans.
5. Does NPE cover the delivery?
No. By definition, NPE is only for the newborn. For questions about coverage of the mother’s delivery, see FAQs #29 and #31.
NPE Process Clarifications
6. Does the family need to also apply for TennCare for the newborn using the regular process?
Yes. See FAQs #2 and #4. Qualified entities should help all NPE applicants apply via healthcare.gov and/or provide a hard copy of the FFM application form.
7. Can a mother already enrolled in TennCare use the NPE process?
No. The NPE process is for women who do not have TennCare at the time that they deliver.
If a new mother is already enrolled in TennCare when she presents for delivery, she should not complete the NPE Form. Once the birth to the mother enrolled in TennCare is reported, TennCare will simply “deem” or add the newborn to the mother’s case (and her managed care organization or “MCO”). See FAQ #26.
8. Can a mother with commercial coverage use the NPE process?
Yes. The NPE process is for women who do not have TennCare at the time that they deliver. Women with commercial coverage (e.g., employer-sponsored health insurance) can use the NPE process as long as they do not already have TennCare. The fact that a woman has commercial insurance does not disqualify her or her infant from being eligible for TennCare.
For example, a 22-year-old female on her parent’s health insurance delivers a newborn.
The 22-year-old does not have TennCare at the time of delivery, but she would like to apply for her newborn. She can complete the NPE process and enroll her eligible newborn. She will subsequently need to notify TennCare of any other health insurance that the newborn has (once enrolled in the other insurance).
Yes, any newborn (age 12 months or younger) may enroll through a qualified entity using the NPE process. However, the effective date of coverage will be the date the eligibility determination. See FAQ #3.
10. Can a child older than 12 months enroll through the NPE process?
No. The NPE process is only for newborns (those children 12 months or younger). Older children who need coverage through TennCare or CoverKids may apply at healthcare.gov or by calling 1-800-318-2596 – or enroll via the Hospital PE process at a participating hospital.
11. Can a family over 195% FPL enroll a newborn in CoverKids or TennCare Spenddown through the NPE process?
No. If an applicant self-reported monthly household income above the TennCare income limit for newborns (i.e., 195% FPL), then the employee of the qualified entity would need to deny NPE. The employee would then explain that the applicant could apply at healthcare.gov for TennCare and other programs (including CoverKids) and provide an NPE Eligibility Notice noting the denial. See FAQ #2.
12. Can noncitizen mothers use the NPE process for their U.S.-born newborns?
Yes. The NPE process is based upon the citizenship of the newborns, who are natural-born U.S. citizens. For questions about coverage of the mother’s delivery, see FAQs #29 and #31.
13. Can a parent apply through the NPE process if the baby does not yet have a name?
Applicants must have a name for the baby in order to use the NPE process. Because the effective date of coverage is the date of the eligibility determination, the mother should sign this form on her date of delivery if at all possible – even if she has not yet named the child.
The mother may add the newborn’s name to the NPE Form a day later if necessary.
However, the hospital or birthing center must transmit the information within five (5) working days to TennCare via TennCare Online Services. Please note that five-day reporting requirement is determined by federal rules. See 42 CFR § 435.1102(b)(2)(ii).
14. Must the parent complete all fields on the NPE Form?
The only fields that are optional on the NPE Form are the baby’s SSN and the mother’s SSN. All other fields (including the baby’s name) are required fields for a complete form.
Hospitals and birthing centers cannot process incomplete forms and should not submit data for such newborns to the State via TennCare Online Services.
Yes. Parents may apply for SSI and also use the NPE process to ensure that the newborn has coverage as quickly as possible. Please remind the parents that, like any other NPE applicant, they must apply for TennCare at www.healthcare.gov by the end of the next month or they may lose TennCare coverage. This is especially important if the newborn’s SSI application remains pending. Even though SSI, if approved, is retroactive to the date of application, there could be a coverage gap if the parents do not apply for TennCare while the SSI application is pending.
Newborns Entering DCS Custody
16. Can a newborn entering DCS custody apply through the NPE process?
Yes. Newborns that may enter DCS custody can, and should, apply through the NPE process to ensure they have coverage as quickly as possible. Hospitals and birthing centers should complete the NPE form and indicate on the form that the newborn will be entering DCS custody but is not in DCS custody yet. All fields must be completed as described above; however, the mother’s information will not be included. TennCare will only accept NPE forms without the mother’s information if the NPE form indicates that the newborn is entering DCS custody but is not in DCS custody yet. Once the newborn is in DCS custody they will be enrolled through the “Immediate Eligibility” process with DCS.
While hospitals and birthing centers shall transmit data for all other newborns using the electronic process, they can fax this small subset of newborns to 615-734-5388.
17. Can a newborn whose mother decides to utilize the Safe Haven program apply through the NPE process?
Yes. Newborns who are a part of the “Safe Haven” program can, and should, apply through the NPE process to ensure they have coverage as quickly as possible. Hospitals and birthing centers should complete the NPE form and indicate on the form that the newborn is a part of the “Safe Haven” program. All fields must be completed as described above;
however, the mother’s information will not be included. TennCare will only accept NPE forms without the mother’s information if the NPE form indicates that the newborn is a part of the “Safe Haven” program. Once the newborn is in DCS custody they will be enrolled through the “Immediate Eligibility” process with DCS. While hospitals and birthing centers shall transmit data for all other newborns using the electronic process, they can fax this small subset of newborns to 615-734-5388.
18. What is the effective date of eligibility for newborns entering DCS custody who apply through the NPE process?
If a newborn is entering DCS custody and his/her mother is currently enrolled in TennCare, the hospital or birthing center should indicate this on the NPE Form and the newborn will receive eligibility beginning from the date of birth. If a newborn is entering DCS custody and the mother is not enrolled in TennCare or CoverKids on the newborn’s date of birth, the newborn will receive eligibility beginning from the date of the eligibility determination.
19. Who counts as part of the applicant’s household size?
The household consists of the following individuals who live together:
the new mother;
her newborn baby; and her natural, adopted, or step-children under age 21.
The applicant should not count an unmarried father as part of the household since he is not being claimed as a tax dependent by anyone in the household.
For example, a single 29-year-old woman who gives birth to twins would be a household of three if she has no other children or married spouse. If she were married and had two other minor children, then she would have a household of a six (herself, her husband, her twins, and her two other minor children).
The same rules generally apply for mothers under age 19. In most cases, the household for the newborn would consist of the newborn, the minor mother, her spouse (if any), and any of her other children in the home. The newborn's household would generally not include any grandparents. Follow this approach when using the NPE process.
For example, an unmarried, pregnant 17-year-old lives with her parents. The 17-year-old has no other children. When she gives birth, the newborn's household size would be two (the 17-year-old mother and the infant). The only income counted for the newborn’s household would be the 17-year-old mother's. The grandparents would not be part of the newborn's household, and the grandparents' income would not be considered.
20. What counts in terms of monthly income for the applicant’s household?