«Important Note: TennCare implemented the Newborn PE (NPE) program on August 18, 2014. In the interest of expediency, we implemented the Newborn PE ...»
As noted on the NPE Form, the applicant should include the before-tax amounts of wages, salaries, and self-employed income received by adult household members. The applicant should also include unemployment, alimony received, and Social Security Disability Income (SSDI) for household members. However, the applicant should not include Supplemental Security Income (SSI) or child support.
For example, a pregnant, 31-year-old divorcee receives $1,050 per month in alimony, and she nets $1,400 per month in self-employed income as a nail technician. She also works part-time as a receptionist and earns $400 each month before taxes in wages. In addition, she receives $600 in child support for her eight-year-old son. Her countable income is $2,850 (i.e., $1,050 in alimony received + $1,400 in self-employed income + $400 in wages).
Yes. Please note that newborns born in the U.S. are automatically U.S. citizens and should answer “yes” to this question on the NPE Form. For more information about which immigrants are eligible for TennCare, see the “Immigration Reference Table” on p. 7 the guidance entitled “Providing Eligibility Assistance for Pregnant Women and Newborns: A Step-by-Step Guide for Hospitals and Birthing Centers” located under the providers tab at www.tn.gov/tenncare.
22. Who actually determines eligibility under the NPE process?
Employees of qualified entities determine newborn presumptive eligibility. See FAQ #2.
23. What are the requirements to be a qualified entity?
Only participating hospitals and birthing centers can be qualified entities for the NPE process. Qualified entities must also have legal agreements and SFTP2 access with TennCare, and they must train employees to perform this function. More information is available in the provider transmittal from TennCare dated August 7, 2014 under the providers tab at www.tn.gov/tenncare.
24. Can a qualified entity use the NPE process for a newborn transferred there?
Yes. Qualified entities can use the NPE process even for newborns who are born at another facility. However, please ensure that the other facility has not already completed the NPE process for the newborn.
25. Can hospitals and birthing centers that are qualified entities delegate NPE determinations to contractors?
No. Federal rules at 42 CFR § 435.1102(b)(2)(vi) for presumptive eligibility for children (in our case, newborns) do not allow qualified entities to delegate presumptive eligibility determinations to another party. Employees of qualified entities, not contractors, must determine newborn presumptive eligibility. Note, though, that this restriction with the NPE process affects only a relatively small number of cases (i.e., those in which the mothers present for delivery without TennCare coverage).
While contractors cannot determine eligibility under the NPE process, contractors can help in a number of critically important ways. First, contractors can still help NPE applicants complete the full TennCare application process at healthcare.gov. Second, contractors can help the much larger number of pregnant women who present with TennCare and CoverKids at the time of their delivery to report their births. Third, contractors can help uninsured pregnant women apply for CoverKids if they are ineligible for TennCare. This is an alternative to the “emergency TennCare” process; see FAQs #29 and #31.
26. What is the difference between the existing “deeming” process in TennCare and NPE?
If a new mother is already enrolled in TennCare at the time she delivers, TennCare will simply “deem” or add the newborn to the mother’s case and MCO. If instead a new mother is under TennCare income limit but not enrolled in TennCare at the time that she delivers, TennCare cannot “deem” the infant. In this circumstance, the new mother can sign up her newborn for TennCare through the NPE process.
For example, Sarah is enrolled in TennCare when she gives birth. When TennCare learns of the birth, it will “deem” Sarah’s baby as eligible for TennCare and add the newborn to Sarah’s case and MCO. Jane, in contrast, is not enrolled in TennCare when she gives birth even though she is under the TennCare income limit. Jane can enroll her newborn in TennCare using the NPE process; separately, she can also apply for TennCare (or CoverKids, if appropriate) to cover her delivery if she gets her application in by the day of delivery.
Hospitals can report newborns born to mothers already in TennCare using the newborn interface on TennCare Online Services. TennCare will then “deem” these newborns and process their eligibility accordingly. As has been our policy, TennCare will cover an infant born to a mother enrolled in TennCare for up to 30 days under the mother’s ID number.
27. Does this new NPE program change the existing pregnancy presumptive eligibility process in TennCare?
No. Eligible pregnant women can still go to a local health department1 to apply for presumptive eligibility for TennCare in order to cover their prenatal services. This process remains unchanged. As long as a presumptively-eligible pregnant woman completes a full TennCare application by the end of the following month, she will retain her TennCare coverage at least until the FFM makes a determination for full TennCare based on her FFM application. If the FFM determines her to be eligible under the pregnancy category, she will retain coverage at least for the remainder of her pregnancy and the 60-day post-partum period. If the mother is enrolled in TennCare at the time the baby is born, the baby will be “deemed” eligible for TennCare when the mother reports the birth.
Of course, some applicants will not be eligible for pregnancy presumptive eligibility. These pregnant women may be eligible for CoverKids.2 As before, they can apply for coverage of prenatal services and delivery at www.healthcare.gov – or by faxing the CoverKids application directly to CoverKids. If the mother has CoverKids at the time that she gives birth, CoverKids will determine whether the baby is eligible for TennCare or CoverKids and will take the appropriate action to facilitate coverage for the newborn.
A list of local health departments by county is available at http://health.state.tn.us/localdepartments.htm.
Generally speaking, a pregnant woman must be a U.S. citizen or eligible immigrant in order to qualify for TennCare coverage. However, the unborn children of noncitizens at or below 250% FPL are eligible for coverage through CoverKids. This means that pregnant noncitizens at or below 250% FPL can receive both prenatal care and delivery services through CoverKids if they are ineligible for Medicaid because of their immigration status.
28. How can a CoverKids enrollee report the birth to CoverKids?
If a pregnant woman is already enrolled in CoverKids when she gives birth, simply call CoverKids at 1-866-620-8864 (toll-free) to report the birth. CoverKids will determine whether the baby is eligible for TennCare or CoverKids and will take the appropriate action to facilitate coverage for the newborn. Please encourage mothers to call CoverKids to report her baby as promptly as possible.
Do not report births of CoverKids enrollees via TennCare Online Services.
Several hospitals asked whether they could report births of CoverKids enrollees to the CoverKids program on behalf of the new mothers (provided that the hospitals had the mothers’ authorization). We now offer a process in which hospitals and birthing centers can fax a “CoverKids Birth Reporting Form” to CoverKids to accomplish this goal. The new form is available under the Providers tab at www.tn.gov/tenncare. Note: This is a “fillable” form, and we ask you to type the information into the form to expedite processing.
29. Can CoverKids cover the delivery of women who are not eligible for TennCare?
Yes, if the women meet the income requirements and if she applies on or before the date of her delivery. More information is available in the guidance entitled “Providing Eligibility Assistance for Pregnant Women and Newborns: A Step-by-Step Guide for Hospitals and Birthing Centers” under the Providers tab at www.tn.gov/tenncare.
Please use the NPE process to assess the newborn for NPE if the woman does not have CoverKids or TennCare at the time of her delivery – even if the woman is applying for coverage for her delivery. This will allow TennCare to add eligible newborns even while the mother’s application is pending at CoverKids or TennCare.
30. What is the effective date of coverage for a newborn whose mother was enrolled in CoverKids at the time of delivery?
The newborn will receive coverage effective as of the date of birth. Depending on the household’s income and size, the newborn’s coverage may be through TennCare or through CoverKids. In either case, the family can simply call 1-866-620-8864 to add the baby. We will add the newborn to the appropriate program and begin coverage on the date of birth.
Submitting Information to TennCare
31. How do I submit newborn information to TennCare?
Hospitals should submit all newborn information (for both presumptively eligible and deemed newborns) via TennCare Online Services. For more information about TennCare Online Services, visit http://www.tn.gov/main/article/tenncare.
No. You should submit data only for approvals; you should not transmit information on cases that you deny (e.g., because the applicant was over the TennCare income limit).
33. Once I submit a newborn’s information via TennCare Online Services, do I still need to fax birth certificates for deemed newborns?
No, you simply report all information for newborns via TennCare Online Services.
34. Can we report births to CoverKids enrollees via TennCare Online Services?
No. TennCare Online Services is only for “deemed” newborns and presumptively eligible newborns whom we need to enroll in TennCare. See FAQ #28 about reporting births to CoverKids.
35. How will a provider be able to confirm a newborn’s TennCare enrollment?
Health care providers typically verify TennCare eligibility using our TN Anytime/TennCare Online Services system. Our system requires the patient’s SSN in order to perform the eligibility lookup. However, few if any of newborns eligible through the NPE process will have SSNs. As a result, health care providers will be unable to confirm the eligibility of these newborns using the TN Anytime/TennCare Online Services.
Even so, providers have several options. First, those providers that use Emdeon, Passport, or similar vendor are often able to look up patients using name and date of birth. Second, providers can look up eligibility for United HealthCare members through either Optum Cloud or their RV eservices website using only name and DOB without needing SSN. Similarly, providers can do a name lookup using the BlueCross BlueShield of Tennessee portal.
AmeriGroup does not allow for name lookups on their portal but allows providers to call their Customer Service Line at 1-800-454-3730 for assistance. Third, TennCare will mail the newborn’s welcome packet within two business days of completing the enrollment; the packet confirms eligibility, MCO assignment, and effective date – and the MCO will follow with member ID cards shortly thereafter. In the event that providers are still unable to verify eligibility for a specific newborn after exhausting these options, they may contact Brian Haile at TennCare.
36. Does a hospital or birthing center need to keep copies of the NPE Forms even after submitting the information via TennCare Online Services?
Yes. As noted in the instructions on the NPE Form, “Qualified hospitals and birthing centers shall retain this form for seven (7) years.”