Tennessee Department of Human Services

Medicaid/TennCare Coverage Groups

There are two primary classifications of Medicaid: Categorically Needy & Medically Needy. Medicaid coverage to those that are considered Categorically Needy includes:

· Recipients of Families First Cash Assistance
· Pregnant women and certain children of a specified age (to age 19) whose family gross income does not exceed the Federal Poverty Level Income Standard. If a woman is eligible during her pregnancy, she will receive two months of postpartum coverage.
·Medicaid only - Ineligible for Families First because of a requirement which does not apply in Medicaid.
·Transitional Medicaid - Medicaid is available for 18 months after a participant leaves the Families First Program.
·Newborns are eligible for their first year when born to a Medicaid eligible woman.
·Caretakers of Deprived SSI-eligible children.
·Recipients of Supplemental Security Income (SSI)
·Institutionalized individuals: aged, blind or disabled who would be SSI or FF eligible except for their institutionalization. Individuals receiving Home and Community Based Services (HCBS) are considered institutional.
·SSI Pass-Along or Title II terminations: individuals who receive Social Security and lost SSI eligibility since 4/1977, and who would still be eligible for SSI if their cost of living adjustments were deducted. Includes Disabled Adult Children (DAC)
·Pickle Cases : Individuals who receive Social Security, and lost SSI since 4/1977, for any reason and would be eligible if cost of living adjustment were disregarded. Includes Disabled Widow(er)s who lost SSI due to elimination of the actuarial reduction factor; those at age 60 who lost SSI due to Title II retirement entitlement or who became eligible for Title II due to change in SSA Disability criteria for widow(er)s effective 1/1/1991, and who do not have Medicare coverage.
·Qualified Disabled Working Individuals (QDWI) - disabled working individuals under age 65 and entitled to Medicare premium paid (Part A), if income < 200% of poverty and resources do not exceed 200% of the SSI limit. [Effective 7/1/1990]
·Qualified Medicare Beneficiary (QMB) coverage provides Medicaid coverage of Medicare covered services by paying the Medicare premium, coinsurance and deductibles of eligible individuals. The individual must be eligible for Medicare Part A (hospital insurance) and meet income and resource standards.
·Special Low Income Medicare Beneficiary (SLMB) pays Part B premium only for individuals whose income is equal or less than 120% poverty level and meet resource test.
·Qualifying Individuals (QI1) pays Part B premium on "first come, first served" basis as allowed by 100% federally financed state allocation if all requirements are met for SLMB except that income is greater that 120% of poverty level but does not exceed 135% of poverty level.