Professional Documents
Culture Documents
State of Tennessee
Division of TennCare
P.O. Box 305240
Nashville, TN 37230-5240
October 4, 2019
ANGELA FAULKNER
685 VINTON AVE
ERWIN TN 37650-1013
We were asked to send you the letter(s) in this envelope again. If you have questions or need
more help, please call TennCare Connect at 855-259-0701.
Dev: 02Jul18
Need special help? Need to report a change? Have questions? Call us.
TennCare Connect 855-259-0701
We’re here to help you Monday through Friday, 7 a.m. to 7 p.m.
This page is left blank on purpose.
Dev: 02Jul18
TN 316
State of Tennessee
Division of TennCare
P.O. Box 305240
Nashville, TN 37230-5240
October 2, 2019
ANGELA FAULKNER
685 VINTON AVE
ERWIN TN 37650-1013
We’ve made a change to how we send our letters. When possible, we try to put all of the letters
mailing to your household on the same day in one envelope.
That means there may be more than one letter in this envelope for you. Be sure to look through
all of the pages so you don’t miss important news!
If you have questions or need more help, please call TennCare Connect at 855-259-0701.
Dev: 02Jul18 1
Need special help? Need to report a change? Have questions? Call us.
TennCare Connect 855-259-0701
We’re here to help you Monday through Friday, 7 a.m. to 7 p.m.
This page is left blank on purpose.
Dev: 02Jul18 2
TN 301.3
State of Tennessee
Division of TennCare
P.O. Box 305240
Nashville, TN 37230-5240
October 2, 2019
ANGELA FAULKNER
685 VINTON AVE
ERWIN TN 37650-1013
Notice of Decision
This letter tells you about the decision we made for each person in your home when we
received or you reported a change. Before we made our decision, we looked at you for
different kinds of coverage.
If you don’t qualify for a kind of coverage, we will tell you why. If your coverage changes or is
ending, we will tell you when and why.
Each part of this letter tells you more about our decision.
Rev: 28Jul19 3
Need special help? Need to report a change? Have questions? Call us.
TennCare Connect 855-259-0701
We’re here to help you Monday through Friday, 7 a.m. to 7 p.m.
TN 301.3
If you think we made a mistake about your start date or the kind of coverage you get, you can file
an appeal. This letter will tell you how to file an appeal.
s
s
Who is approved: ANGELA FAULKNER (Age: 44)
Program: Date(s):
TennCare Medicaid Continued Coverage
s
s
Who is approved: MICAH G FAULKNER (Age: 5)
Program: Date(s):
CoverKids Continued Coverage
Other facts about our review:
Before we made our decision, we looked to see if you could get other kinds of coverage we
offer. Here’s why you don’t qualify.
TennCare Medicaid -
The monthly income limit for the kind of TennCare Medicaid you could get is $3,048.00. Our
records show your monthly income is over this limit. [Tenn.Comp.R&R 1200-13-20]
TennCare Medicaid -
We looked to see if you could get a kind of TennCare Medicaid called Spend Down. To meet
Spend Down, you can sometimes use medical bills to help lower your income. The monthly
income limit for Spend Down is $325.00. Your monthly income is over this limit. [Tenn.Comp.R&R
1200-13-20]
Do you think we made a mistake? If so, you can file an appeal. When you appeal, you’re asking
to tell your side to a judge or hearing officer. It’s called a fair hearing.
s
Reasons you can have a fair hearing may include:
Your income is less than $3,048.00.
You do have enough qualifying medical bills to meet your Spend Down amount, so you are not
over the income limit for TennCare Medicaid.
Rev: 28Jul19 4
Need special help? Need to report a change? Have questions? Call us.
TennCare Connect 855-259-0701
We’re here to help you Monday through Friday, 7 a.m. to 7 p.m.
TN 301.3
Were you denied and think we made a mistake? You have until November 11, 2019 to
file an appeal.
Before we give you a hearing, we’ll check to see if we made a mistake. If we decide you’re right,
we’ll fix the problem.
Rev: 28Jul19 5
Need special help? Need to report a change? Have questions? Call us.
TennCare Connect 855-259-0701
We’re here to help you Monday through Friday, 7 a.m. to 7 p.m.
TN 301.3
2. Or, appeal in writing. You can get an appeal page from our website.
Go to https://tn.gov/tenncare. Click “Members/Applicants” then click on “How to file an
eligibility appeal.” Or, you can write your appeal on plain paper. If you write your appeal on
plain paper, be sure you include:
Someone who has the legal right to act for you can also file an appeal for you. Legal Services or
Legal Aid may give you free help with your appeal. To find a Legal Aid or Legal Services office
in your area, go to https://tn.gov/tenncare. Click “Members/Applicants.” Then click on “How
to file an eligibility appeal.”
You may also need to give us proof we need to make the change. There are several ways to tell
us about these changes. See the “How to Report Changes or Send Information to TennCare”
page at the end of this letter.
Rev: 28Jul19 6
Need special help? Need to report a change? Have questions? Call us.
TennCare Connect 855-259-0701
We’re here to help you Monday through Friday, 7 a.m. to 7 p.m.
TN 301.3
· Do you have a mental illness and need help with this letter?
The TennCare Advocacy Program can help you.
Call them for free at 800-758-1638.
People who lie on purpose to get TennCare or CoverKids may be fined or sent to jail.
Rev: 28Jul19 7
Need special help? Need to report a change? Have questions? Call us.
TennCare Connect 855-259-0701
We’re here to help you Monday through Friday, 7 a.m. to 7 p.m.
TN 301.3
This page tells you how to send us proof or information we need from you.
Be sure to keep the originals for your records. Send us a copy.
There are several ways to get this to us. You only have to pick one:
1. Use your online account at https://tenncareconnect.tn.gov. With TennCare Connect you can
also view your case information, update your records, renew your coverage when it’s time
and view your letters.
2. Use the TennCare Connect mobile app. Using the app, you can take a photo of the file(s) we
need and send it to us right from your phone! With TennCare Connect you can also view
your case information, update your records and view your letters.
Haven’t downloaded it yet? Go to the iTunes or Google Play store and look for TennCare
Connect. After installing the app, create an account by clicking the Create Account button.
You’ll need to enter your Social Security Number (SSN) to link your case to your TennCare
Connect account. Or you can enter your Person ID which is found in this letter next to your
name.
Rev: 28Jul19 8
Need special help? Need to report a change? Have questions? Call us.
TennCare Connect 855-259-0701
We’re here to help you Monday through Friday, 7 a.m. to 7 p.m.
A110c
We will send you a different letter that tells you who your health plan is and how to reach them.
Your health plan will help you get the care you need. And they will send you a handbook that
tells you about the services we cover and lists doctors and other places that take your plan.
Do you need to know who your health plan is now? Call TennCare Connect for free at
855-259-0701.
In an emergency, call 911 or go to the closest emergency room. We pay for emergencies even
if the doctor or hospital isn’t in your health plan. Will we pay for other care you get from a place
that’s not in your health plan? Only if you have an OK from your health plan before you get that
care.
What if you have trouble getting health care? If you need help getting care, always call
your health plan first. If you still have problems, call the TennCare Solutions Unit free at
800-878-3192. They can help you with your problem. Or, they can help you file a medical
appeal.
Do you have a hearing or speech problem? To use a TTY/TDD machine, call 866-771-7043.
What about pharmacy benefits?
· Were you approved for TennCare? Adults age 21 or older must pay a co-pay for each
prescription. Children under age 21 do not have a co-pay for prescriptions. Your
handbook will tell you more about any co-pays and your prescription benefits.
· Were you approved for TennCare and also have Medicare? Medicare will pay for
your prescriptions through a Medicare Part D drug plan. TennCare only pays for
prescriptions if you are under age 21, and it’s a medicine TennCare covers and that
Medicare doesn’t cover.
· Were you approved for CoverKids? You may have to pay a co-pay for your
prescription drugs. Your handbook will tell you more about any co-pays and your
prescription benefits.
What about dental care?
· Were you approved for TennCare? TennCare only covers dental care for children
under age 21. Your TennCare handbook will tell you more about your dental coverage
with TennCare.
· Were you approved for CoverKids? CoverKids only covers dental care for children
under age 19. Your CoverKids handbook will tell you more you about your dental
coverage with CoverKids.
Children must use dentists who take their health plan. You don’t need a different card for
dental care. Just show them this letter or your health care card.
Do you still have questions about who your dental plan is? Call TennCare Connect for free at
855-259-0701.
Dev: 02Jul18 9
This page is left blank on purpose.
Rev: 28Jul19 10
TN A003.17
Do you have questions or need help with TennCare? Or, do you need help because you have a
health, mental health, learning problem or disability?
Call TennCare Connect at 855-259-0701.
Do you have a hearing or speech problem and have questions or need help?
Call the Tennessee Relay Services (TNRS) at 800-848-0298. Ask them to connect you
with the TennCare Connect at 855-259-0701.
Do you have questions about Medicare for people over age 65 and for the disabled?
Call Tennessee’s State Health Insurance Assistance Program (SHIP)
at 877-801-0044.
Do you need help getting health care, mental health care or drug or alcohol treatment?
First, call your health plan. If you still need help call the TennCare Advocacy Program
at 800-758-1638.
Then, if you still need help, call the TennCare Solutions Unit at 800-878-3192.
Dev: 02Jul18 11
TN A003.17
U.S. Department of Health & Human Services Office for Civil Rights
200 Independence Ave SW, Rm 509F, HHH Bldg
Washington, DC 20201
Phone: 800-368-1019
(TDD): 800-537-7697
Dev: 02Jul18 12
TN A014.7
Arabic:
Chinese:
Vietnamese:
Korean:
French: Français
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés
gratuitement. Appelez le 855-259-0701 (ATS: 800-848-0298).
Amharic:
Gujarati:
Laotian:
German: Deutsch
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen
zur Verfügung. Rufnummer: 855-259-0701 (TTY: 800-848-0298).
Tagalog: Tagalog
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa
wika nang walang bayad. Tumawag sa 855-259-0701 (TTY: 800-848-0298).
Dev: 02Jul18 13
TN A014.7
Hindi:
Serbo-Croatian: Srpsko-hrvatski
OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno.
Nazovite 855-259-0701 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom:
800-848-0298).
Russian:
Nepali:
Persian:
Dev: 02Jul18 14