↦

Fill Out Your Tenncare Renewal Packet Form

The Tenncare Renewal Packet form is a crucial document for Tennessee residents seeking to maintain their eligibility for healthcare services provided through TennCare. This form is specifically designed for individuals in nursing homes, those aged 65 and older, individuals with physical disabilities, and those needing community support services. Completing this form is essential to ensure continued access to vital healthcare services and financial assistance.

If you need to fill out the Tenncare Renewal Packet, click the button below to get started.

Launch Tenncare Renewal Packet Editor Now

Launch Tenncare Renewal Packet Editor Now

Article Structure

The TennCare Renewal Packet form serves as a critical resource for various Tennessee residents seeking assistance with healthcare services. Designed for individuals needing long-term services and supports, the form specifically applies to those who may require care in a nursing home or who are eligible for services to remain in their homes and communities. This includes Tennessee residents aged 65 and older, or younger adults with physical disabilities, who wish to avoid institutional care. It also covers individuals with intellectual or developmental disabilities needing community-based services, as well as those requiring care in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) or hospice care in a nursing home. Furthermore, the form facilitates applications for Medicare cost-sharing programs, assisting residents with premiums, co-pays, and deductibles associated with Medicare coverage. To apply using this packet, individuals can mail or fax their completed forms to TennCare Connect, ensuring they include necessary details about themselves and other household members, as well as proof of income and ownership of assets. The form accommodates applicants who may need assistance completing the application, allowing for designated authorized representatives to act on their behalf. With comprehensive instructions and contacts for help, the TennCare Renewal Packet is a vital step for many in accessing essential healthcare services in Tennessee.

Tenncare Renewal Packet Example

TN residents who need care in a nursing home.

TN residents age 65 and older or 21 and older with a physical disability who need services in their home and community to keep from going into a nursing home.

TN residents who have an intellectual or developmental disability and need services in the community. TN residents who have an intellectual disability and need care in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID).

TN residents who need hospice care in a nursing home.

TN residents who have Medicare and want to apply for help paying their Medicare cost sharing, like QMB, SLMB, QDWI, or QI1. If you qualify, TennCare pays your Medicare premiums and sometimes your Medicare co-pays, and deductibles.

LTSS and MSP APPLICATION.3

Page 1 of 9

TENNCARE

Who should use this application?



Application for someone who:

Is in a nursing home or ICF/IID (read more below)

Wants Home and Community Based Services (like CHOICES or Employment and Community First CHOICES)

Needs Hospice Care in a nursing home

Wants help paying for Medicare (like QMB or SLMB)

Mail this application to TennCare Connect, P.O. Box 305240 Nashville, TN 37230-5240. Or fax it to

855-315-0669. If you don’t need long term services and supports or help with your Medicare costs but you want to apply for TennCare go to www.healthcare.gov.

Is someone helping you fill out these pages?

You can choose an authorized representative.

Yes

You can give a trusted person permission to:

talk about this application and your health care with us,

see your information,

act for you on matters related to this application and your coverage (including getting information about this application),

receive all notices or other communications about your application,

and sign this application on your behalf.

This person is called an “authorized representative.” If you ever need to change your authorized representative, contact TennCare Connect at 855-259-0701. If you’re a legally appointed representative for someone on this application, submit proof with the application (if you haven’t already given us this proof). You must also

complete and send us the TennCare Authorized Representative – Individual page found on our website at

https://tn.gov/tenncare/topic/hipaa-forms.

If yes, then tell us: Their name _______________________________________________________________

Their phone number: (______) ________________________ - or - (_______) __________________________

Address: __________________________________________ Apartment or Suite Number_________________

City: ________________________________________ State: ___________ Zip Code: ___________________

E-Mail Address: ______________________________ ID Number (if applicable): _______________________

Organization name (if applicable): _____________________________________________________________

Is it okay for us to talk to this person about your case?	Yes No
TC0131 Rev: 30Oct18	RDA 2047

If you need help, call 855-259-0701. It’s a free call.

LTSS and MSP APPLICATION.3

Page 2 of 9

1.Tell us WHO you are, WHERE you live and WHERE you get your mail.

Name: ____________________________________________________________________________________

Home address (NOT a P.O. Box): ______________________________________________________________

City: ________________________________________ State: ___________ Zip Code: ___________________

Mailing address, if different: __________________________________________________________________

City: ________________________________________ State: ___________ Zip Code: ___________________

Phone: (________) ___________-________________ - or - (________) ___________-___________________

Do you intend to be a Tennessee resident? Yes

You cannot receive TennCare Medicaid if you receive Medicaid benefits from another state. We can help tell

the other state you want to stop your Medicaid in that state. We will only contact the other state if you would be eligible for TennCare Medicaid. If you don’t want our help, you will need to end out-of-state Medicaid

before you get TennCare Medicaid.

Do you receive Medicaid benefits in another state? Yes

If yes, do you want us to ask that state to stop your Medicaid? Yes

Please answer these questions:

If yes, which state? ____________________

What’s the best time to reach you by phone? _____________________________________________________

I am using this application to apply for:

Help paying for Nursing Home care

Home and Community Based Services (HCBS) for older adults and adults with physical disabilities

Do you think you need care at home to keep from going into a nursing facility? Call your Area Agency on Aging and Disability at 866-836-6678. You still need to finish this application, but they can help you.

Medicare Savings Program to help with my Medicare costs

Hospice Services in a nursing home

Care in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)

Home and Community Based Services (HCBS) for Individuals with Intellectual and/or other Developmental Disabilities – like Employment and Community First CHOICES

Do you think you need care at home to keep from going into a nursing facility? Then you must also complete an online referral at: https://tcreq.tn.gov/tmtrack/ecf/index.htm.

If you need help, call the Department of Developmental and Intellectual Disabilities in the area where you live:

West TN: 866-372-5709,

Middle TN: 800-654-4839, or

East TN: 888-531-9876.

Keep reading. You still need to finish this application.

Are you homeless now? Yes No

What language do you speak best?

What language do you read best?

Do you have a disability? Yes No


	Are you living in a shelter? Yes		No
English	Spanish	Other Language ______________
English	Spanish	Other Language ______________

If yes, what is it? ___________________________________

If you do, do you need us to help you with these papers? Yes

TC0131 Rev: 30Oct18

RDA 2047

If you need help, call 855-259-0701. It’s a free call.

LTSS and MSP APPLICATION.3

Page 3 of 9

2.Tell us everyone who lives in your home now. Tell us who they are even if

they don’t have TennCare or if they don’t want TennCare. List yourself first. You can add more pages if you need to.

Is there someone living with you that wants TennCare but does not want long term services and supports? They must apply online at www.healthcare.gov. Or, they can call TennCare Connect at 855-259-0701.

Who lives in your home now?	Does this	Date of	Social Security number:	How is this	Sex	Want to tell
List yourself first.	person want	Birth	ONLY if	person related		us your Race?
Full Name –	to qualify for	(Month/	this person wants	to you?	M /F	***
Full Name –	coverage	Day/Year)	coverage			(W, B, Y,
First, Middle Initial, Last	listed on the					A, H, I or O)
	previous
	page?
	Yes
	No
	Yes
	No
	Yes
	No
	Yes
	No

***If you want to tell us your race, please use these letters.

A = Asian H = Native Hawaiian or Pacific Islander

W = White	B = Black or African-American	Y = Hispanic
I = American Indian or Alaskan Native		O = Other

3.Answer these questions about you and all the people living in your home.

Are you a U.S. citizen, legal alien or eligible immigrant? Yes INS papers.

If no, we will need a copy of your

Does any child living in your household have a parent who doesn’t live there too?

Yes

If yes, which child? __________________What is the parent’s name of that child?____________

Does anyone living in your household have a spouse (a husband or wife) who doesn’t live there too?

Yes

If yes, who? _________________________________________________

Why does this person not live in this home? ______________________________________________________

Are you getting care in a nursing home? Yes	No
If yes, what’s the name of the nursing home? _______________________________________________________

When did you start getting care in the nursing home? _________________________________________________

Are you temporarily living out-of-state? Yes	No
If yes, tell us where you’re living and why. _____________________________________________________

To get TennCare, you must prove that Tennessee is your permanent home and you are coming back. Send us proof that Tennessee is your permanent home. Your proof can be something like:

•	Proof that you own or rent a home in Tennessee	•	Your vehicle registration (from Tennessee)
•	Property tax statement for Tennessee	•	Your voter’s registration (from Tennessee)

What city and county do you live in when you are in Tennessee? __________________________________

Do you own or lease a place to live in another state? Yes	No	Which state? _________________
Is anyone a Veteran or in Active Military status? Yes	No
If yes, tell us who. Be sure to tell us their name and social security number.
___________________________________________	_________________________________________
___________________________________________	_________________________________________
TC0131 Rev: 30Oct18		RDA 2047

If you need help, call 855-259-0701. It’s a free call.

LTSS and MSP APPLICATION.3

Page 4 of 9

Do you have other health insurance, including Medicare? If so, tell us:

What is the name of the insurance company? __________________________________________________

What is the policy number? ________________________________________________________________

What is the policyholder’s name? ___________________________________________________________

What is the policyholder’s SSN? ____________________________________________________________

What is the premium amount? ______________________________________________________________

What is the start date? _____________________________________________________________________

What is the relationship of the policy holder to you and others on this application? _____________________

______________________________________________________________________________________


Do the other people listed in number 2 also have this insurance? Yes		No
If yes, tell us the names of the other people who are covered by this same health insurance plan:
___________________________________________	_______________________________________
___________________________________________	________________________________________

Do you (or other people listed in number 2) have health insurance other than the policy listed above? If so, please include the information about that policy on another piece of paper.

4. Send proof of your income.

Does anyone in your home work? Yes	No	If yes, you can send copies of pay stubs or proof of
earnings for the last 2 months for each job. What if you don’t have all your pay stubs for the last 2 months?
Give TennCare copies of all that you have.

Is anyone self-employed? Yes No	If yes, tell us the kind of work they do.____________________

If yes, send copies of their last federal income tax return with all schedule attachments. If you don’t have your tax forms, send other proof. Send something that shows your income and expenses.

Remember - Don’t send the original. Send a copy.

Tell us about any work you get paid for, even odd jobs where you don’t pay taxes.

Name of person	# of	How much		How	Name of Employer				Phone number of
(Who earns this	hours	do they get		often do					Employer
money?)	worked	before taxes		they get	(Are you self-employed? Tell us the
	each	each pay		paid? ***	name of your business if it has one.)
	week	period?

		$

		$

		$

		$

			*** Daily, Weekly, Every 2 weeks, Twice a month, Monthly
Is there an adult in your home with no income? Yes						No	If yes, who? __________________
When did their income stop? ____________				How do they pay the cost of daily living?				For example, living with a

friend or relative, rent is paid by someone, living off savings, etc. ___________________________________

Does anyone get Social Security or SSI or Unemployment payments from Tennessee?

Yes	No	If yes, tell us who. _____________________________________________________________
You don’t have to send proof of this income. We’ll get it for you.

Did you lose Medicare because you went back to work and were making more money than your Social Security income limit? Yes No

TC0131 Rev: 30Oct18

RDA 2047

If you need help, call 855-259-0701. It’s a free call.

LTSS and MSP APPLICATION.3			Page 5 of 9
Does anyone get any of the kinds of income listed below? Yes No
• Money from friends or relatives		•	Workers’ Compensation
•	Retirement Payments	•	Interest/Dividends/Royalties
•	Disability Payments	•	Rental Income
•	Child Support Payments	•	Alimony
• Unemployment Payments from another state		•	Other

•Veteran’s Benefits

If yes, tell us about it in the box below and send proof. Don’t send the original. Send a copy.

Name of person	What	How much	How often?	Who pays them?	What is their
(Who gets this money?)	kind?	do they get?		Who pays them?	Phone Number?
(Who gets this money?)	kind?	do they get?			Phone Number?

		$

		$

		$

		$

5.Tell us if you pay for child care or care for a disabled adult.

Does anyone pay for child care or care for a disabled adult? Yes No

If yes, fill in the boxes below. Send proof that shows who gives the care and how much you pay them. This proof must be signed by the person that gives this care. It must say how much you pay and how often.

Who gets this care?	Who pays for this	How much	How often do	Name and Phone Number of Caregiver
	care?	does it	you pay?
		cost?
		$

		$

6.Tell us what you own. If you need more room, you can add more pages.

You must tell us what you own. What if you don’t tell us about what you own or you’re over the limit? You won’t qualify for TennCare Medicaid in any group that has a resource limit.

Do you own:		What’s it	How much do you	The kind of proof
		worth now?	owe on it?	we need:

Property Tell us these things about the				Something that shows what
property in the space below:				it’s worth like a property tax
				statement
				and something that shows
Street Address:		$	$	how much you owe like a
City:				how much you owe like a
City:				mortgage statement
State:	ZIP:			mortgage statement
State:	ZIP:

Street Address:		$	$
City:
State:	ZIP:


Do you own:		What’s it	How much do you	The kind of proof
		worth now?	owe on it?	we need:

Checking accounts		$		Statement from bank or
Bank Name: _____________________				credit union that shows the
				balance
Savings or credit union accounts		$		balance
Savings or credit union accounts		$
Bank Name: _____________________
Christmas Club accounts		$
Bank Name: _____________________
TC0131 Rev: 30Oct18				RDA 2047

If you need help, call 855-259-0701. It’s a free call.

LTSS and MSP APPLICATION.3							Page 6 of 9

Cars and trucks
Tell us the make, model and year below.
Make_________________________			$		$
Model	Year
Make_________________________			$		$
Model	Year

Make_________________________			$		$
Model	Year
							Payment book or signed
Motorcycles and boats							Payment book or signed
Make_________________________			$		$		statement that says how
Make_________________________			$		$		much you owe
Model	Year						much you owe
Model	Year

Make_________________________			$		$
Model	Year

RVs and campers
Make_________________________			$		$
Model	Year

Trust fund or Estate			$				Copy of legal papers
Trust fund or Estate
Stocks			Current				Bank or investment
Name:________________________			value:				company papers that show:
Number Owned: _______________			$				 the kind of stock or
Number Owned: _______________							 the kind of stock or
Bonds			Current				bonds,
Name:________________________			value:				 how many you own of
Name:________________________			$				 how many you own of
Number Owned: ________________			$				each kind, and
							each kind, and
							 how much they’re worth
IRAs and Keogh Plans			Account				Statement that shows the
			value:				balance. Are you drawing off
			$				this amount? Yes No
							If yes, how much? $

Savings Certificates or CDs			$				Statement from bank that
Tax Shelter Accounts			$				shows the balance
Revocable burial contract			$		$		Copy of the burial contract
Irrevocable burial contract			$		$		Copy of the burial contract

Cemetery Lots			$		$		A deed and something from
How many? __________							the cemetery that shows how
Are the lots for you or members of your							much you could sell the lots
immediate family? Yes	No						for now
If no, for who?_________________
Other (Tell us what):			$		$

Does anyone in your household have a life insurance policy? Yes						No

Tell us who		What is its cash value?		Insurance Company Name and Phone Number
		$

		$

TC0131 Rev: 30Oct18

RDA 2047

If you need help, call 855-259-0701. It’s a free call.

Yes No

LTSS and MSP APPLICATION.3

Page 7 of 9

7.ONLY fill out this part if you:

need care in a long term care facility, even if you can be served safely in your home.

need care at home to keep from going into a long term care facility.

have an intellectual or developmental disability and need care in the community.

need care in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID).

In the last 60 months (5 years), have you sold or given away any of the kinds of things

listed in question 6? Yes No		If yes, fill in the boxes below.

What did you sell or	What was it		How much did	If you sold	The kind of proof
give away?	worth?		you owe on it?	it, how	we need:
				much did
				you get?
	$		$	$	Something that shows:
					 how much it was worth, and
	$		$	$	 how much it was worth, and
					 how much you owed on it,
	$		$	$	 how much you owed on it,
					and
	$		$	$	and
					 how much you sold it for

In the last 12 months (1 year) has anyone in your household gotten a lump sum of money? This could be something like an insurance settlement, back pay for Social security, or a lottery prize.

If yes, fill in the boxes below.

Tell us who	How much did	Where did it come from?	The kind of proof
	this person get?		we need:
	$		Bank records or an award
			letter that shows how much
	$		letter that shows how much
	$		you got.

	$
	$

If you’re applying for CHOICES or Employment and Community First, or Hospice care, you can choose your health plan. If you don’t pick one, TennCare can pick for you. If you’re approved, your approval letter will tell

you who your plan is and how you can change it. The health plans for TennCare are: AmeriGroup, BlueCare, and UnitedHealthcare.

I want my health plan to be:___________________________________________________________________

(Are you applying to get help with your Medicare costs only? If so and you are approved for a Medicare Savings Program like QMB or SLMB you won’t be enrolled in a TennCare health plan.) But TennCare will pay your

Medicare premium for you.

8.Sign here.

I am giving my OK for TennCare to get facts about me and my family. They can get it from other people or agencies. This includes government agencies, employers and places we get health care.

The information I gave on this application is true and complete as far as I know. What if I gave information that’s not true or held back facts on purpose? I could go to jail or have to pay TennCare back. I could also be charged with a crime like perjury or a felony.

Sign Here X: ________________________________________	Date: ________________________
Person Applying / Head of Household

Witness Sign Here (if person applying is unable to sign) X: __________________________________________

Witness Print your name: ____________________________________	Date: ________________________
TC0131 Rev: 30Oct18	RDA 2047

If you need help, call 855-259-0701. It’s a free call.

LTSS and MSP APPLICATION.3

Page 8 of 9

Use this checklist to make sure you are giving us everything we need to work your application. Having all of the information we need will help us work your application faster.

(1) ID and citizenship (i.e. driver’s license and birth certificate) for you, the applicant.

(2) Social Security Number and date of birth for you, the applicant. (This information is optional for your spouse. But, if you can give us his/her SSN and date of birth now, it will help us work your application faster.)

(3) Bank statements for the month of application and two months before that (for each account – checking, savings, IRAs, CDs, stocks, bonds, and 401Ks).

(4) Life insurance policies (owned by you, the applicant, and your spouse) showing company name, address, policy numbers, date issued, face value, and cash value for each policy.

(5) Health insurance premium(s) – including Medicare Supplemental or Medicare Part D Plans.

(6) All gross income for you, the applicant, and your spouse (i.e. Pension, VA Pension, or VA Aid & Attendance, Rental Income, Alimony, etc.)

(7) Vehicle registration (make, model and year), including recreational vehicles.

(8) Property owned (county, address and value), including the home you live in now or lived in before entering a nursing home.

(9) Prepaid burial contracts, including an itemized statement for goods and services and if it’s revocable or irrevocable.

(10) Basic living expenses for your spouse:

Rent or mortgage	Utilities
Property tax	Homeowner’s insurance

(11) All questions in the application have been answered about any dependent children (including disabled adults) who live with you.

(12) Names, phone numbers, and address of two friends or relatives. These are people who can verify you are who you say you are.

(13) All proof of the sale or transfer of any resource made in the last five (5) years (realty, financial, etc.)

(14) Value of Cemetery plots

(15) Marriage certificate (if currently married – not widow/widower)

The items checked above are attached along with your application for Medicaid. Items that are not checked are still needed. Were you asked for items that are not listed above? If so, please tell us the items you are still trying to get:

_____________________________________________	_____________________________________________
_____________________________________________	_____________________________________________
_____________________________________________	____________________________________________

You may be asked to provide more information after the phone interview. The eligibility worker will explain what is needed, how to get it, and will help you get it if you ask.

***Important: The application for Medicaid must be signed. It will take longer for us to process the application if it’s not signed. Be sure to send us this page with the application.***

TC0131 Rev: 30Oct18

RDA 2047

If you need help, call 855-259-0701. It’s a free call.

LTSS and MSP APPLICATION.3

Page 9 of 9

Your Rights and Responsibilities

Keep this page for your records.

Do you need help filling out these pages? Do you have questions?

Call 855-259-0701. It’s a free call.

Do you need help in another language? Let us know. TennCare will get you a free interpreter.

Anyone who wants TennCare must be:

A U.S. citizen or

Legally admitted to the U.S. for permanent residence.

TennCare will use your Social Security numbers to get facts about you and your income.

Those facts will be used to prove you can have TennCare. They will not be used to deport you.

TennCare may give your Social Security numbers to:

Police who are looking for lawbreakers;

Other state or Federal Agencies (but not the INS); and

Collection agencies working to collect money owed to the State.

I’m signing this application under penalty of perjury which means I’ve provided true answers to all the questions on this form and its supplements to the best of my knowledge. I know that I may be subject to penalties under state and federal law if I provide false and or untrue information.

You must tell TennCare Connect if anything changes (and is different than) what you wrote on this application within 10 days of that change. You can call 855-259-0701 to report any changes. You understand that a change in your information could affect the eligibility for member(s) of your household.

Under federal law, discrimination isn’t permitted on the basis of race, color, birthplace, language, sex, age, religion, or disability. If you think you have been treated unfairly, call 855-259-0701 to report it. It’s a free call.

If you are approved, you can’t keep any health insurance or medical payments you get from insurance or other companies. Those payments belong to the State. You must sign them over to the State

What if the Tennessee Bureau of Investigation, the TennCare Office of the Inspector General or another agency asks for your help catching TennCare fraud and abuse? You must help.

If the State pays for medical bills or for nursing home care for you, the State may get that money back. When you die, the State may take money that you owe from your estate.

No one else can use your TennCare card. What if you let someone else use your card? You may have to pay the State back for that other person’s medical bills.

You are giving TennCare your OK to get facts about you and your family from others. This includes government agencies, employers and places you get health care.

If TennCare says you can’t keep TennCare, you can appeal. The letter you get will tell you how to appeal.

If you want to register to vote, you can complete a voter registration form at https://sos.tn.gov/products/elections/register-vote.

TC0131 Rev: 30Oct18

RDA 2047

If you need help, call 855-259-0701. It’s a free call.

Get Tenncare Renewal Packet PDF Form

Form Characteristics

Fact Name	Description
Eligibility Requirements	This form is for Tennessee residents who require nursing home care, are 65 years or older, or are 21 or older with a physical disability needing services to avoid nursing home placement.
Service Types	Eligible applicants can seek assistance for various services, including Hospice care, Community-based services for individuals with disabilities, and Medicare cost-sharing programs.
Authorized Representative	Applicants can appoint an authorized representative who can communicate with TennCare about the application and healthcare matters. Proof of legal appointment must be submitted if applicable.
Application Submission	The completed form must be mailed to TennCare Connect or faxed directly. The mailing address is P.O. Box 305240 Nashville, TN 37230-5240. Fax number is 855-315-0669.
Important Contact Information	If assistance is needed during the application process, applicants can call TennCare Connect at 855-259-0701, a service offered free of charge.

Guidelines on Utilizing Tenncare Renewal Packet

Completing the TennCare Renewal Packet form is an important step towards ensuring you receive the necessary healthcare services you may need. After filling it out, you'll submit it either by mail or fax. It's vital that all sections are filled accurately to avoid delays in processing.

Provide your personal details, including your name, home address (not a P.O. Box), mailing address (if different), and phone number.
Indicate your residency status and whether you receive Medicaid benefits in another state. If applicable, state if you would like assistance stopping Medicaid benefits from that state.
Check if you are applying for specific services, such as nursing home care, Home and Community Based Services, or Medicare Savings Programs.
List everyone who lives in your home, including their names, dates of birth, relationships to you, and whether they want TennCare coverage.
Answer questions regarding your citizenship status, any child living in your home with a parent who does not live there, and other relevant details about your family structure.
Disclose your health insurance status and provide policy details if applicable. Include information about other health insurance coverage for anyone in your household.
Send proof of income for everyone in your household. This includes pay stubs, tax returns, and other income documentation. If someone is unemployed, explain how they manage their daily expenses.
Indicate if anyone in your household pays for child care or care for a disabled adult and provide required proof of payment.
List all assets and their estimated values, including property, bank accounts, and any debts. Be thorough, as this information is critical for eligibility.

After completing all sections, gather any required documents and proof to support your application. Carefully review your form for accuracy to ensure a smooth submission process. When you're ready, mail your completed packet to TennCare Connect or fax it to the designated number provided in the instructions.

What You Should Know About This Form

1. Who should use the TennCare Renewal Packet form?

This form is meant for Tennessee residents who need various types of assistance. If you require care in a nursing home, wish to receive services in your home to avoid visiting a nursing facility, or need hospice care, this form applies to you. It's also for those who are 65 and older or 21 and older with a physical disability. Additionally, individuals with intellectual or developmental disabilities that require community services should use this form.

2. How do I submit the TennCare Renewal Packet form?

You can mail your completed form to TennCare Connect at P.O. Box 305240, Nashville, TN 37230-5240. If you prefer, faxing the form is also an option. The fax number is 855-315-0669. Be sure to keep a copy for your records before submitting!

3. Can I have someone help me fill out the form?

Yes, you may have an authorized representative assist you in filling out the application. This trusted individual can discuss your application and health care needs with TennCare on your behalf. If you need to change this person later, simply contact TennCare Connect at 855-259-0701.

4. What information is needed on the TennCare Renewal Packet form?

You will need to provide personal details such as your name, address, date of birth, and social security number. Information about any other residents in your home, their income, insurance details, and whether you receive Medicaid benefits in another state is also required.

5. How do I report my income accurately on the form?

List all sources of income for yourself and anyone living in your home. This includes wages, self-employment earnings, Social Security, and any other financial support. If you work, you should submit copies of your pay stubs from the last two months. If you’re self-employed, include your last federal tax return along with all attached schedules.

6. What should I do if I am receiving Medicaid benefits from another state?

If you currently receive Medicaid benefits in another state, you will not be eligible for TennCare until you terminate those benefits. You can request TennCare to assist in notifying the other state about the cancellation. This can streamline your transition to TennCare.

7. Can I apply for someone else using this application?

Yes, you can apply on behalf of someone else if you are their legally appointed representative. Be sure to submit the proper proof of your appointment along with the application form to ensure a smooth process.

8. Is there assistance available if I have trouble completing the form?

If you encounter challenges while filling out the TennCare Renewal Packet, help is available. You can call 855-259-0701 for assistance. The call is free, and customer service representatives are ready to guide you through the process.

9. What happens if I do not provide all required information?

Failure to provide complete and accurate information may delay the processing of your application or result in denial of eligibility. It’s crucial to answer all questions thoroughly and attach any requested documentation to avoid complications.

10. How long does the renewal process take?

The time it takes to process your renewal can vary based on several factors, including the completeness of your application and the current workload of TennCare. Generally, you should expect to hear back within a few weeks, but it’s a good idea to track your application by contacting TennCare Connect if you have any concerns.

Common mistakes

Completing the TennCare Renewal Packet is a crucial step for those seeking assistance with healthcare services in Tennessee. However, there are common pitfalls that individuals often encounter when filling out this form. Familiarizing yourself with these mistakes can help ensure a smoother renewal process.

One significant error is not providing a current and accurate home address. The application requires a residential address, and using a P.O. Box instead will lead to delays or even rejection. It’s essential to list a physical address where you reside, as this information is critical for verifying residency qualifications.

Many applicants forget to include important contact information. In addition to the primary phone number, it’s advisable to provide an email address. This way, TennCare can reach you efficiently with any questions or additional information needed regarding your application.

Another frequent mistake is failing to disclose all sources of income. Applicants often miss mentioning part-time jobs, self-employment, or any cash income. Not fully reporting income can result in underestimating eligibility or potential disqualification from services. Ensure that all earnings are documented to provide a complete financial picture.

Errors in the demographic section, including incorrect Social Security numbers or errors when indicating relationship status, can complicate processing. It’s crucial to double-check all names and information against official documents. Simple mistakes may lead to significant delays in receiving care.

Not indicating all individuals living in the household accurately is another important oversight. It’s essential to provide details for everyone, even if they do not apply for TennCare. This information is necessary for assessing the total household income and other qualifications.

Applicants sometimes assume TennCare will keep their status updated if they've provided prior documentation. However, if anything has changed, like a job or household member situation, it's vital to inform them in the renewal packet. Assumption can result in unexpected changes or interruptions in coverage.

Additionally, failing to include supporting documentation can lead to delays. When the application asks for proof of income, assets, or residency, not providing these documents may halt the application process. Be sure to gather necessary paperwork and submit copies as instructed.

Choosing not to designate an authorized representative can be another oversight. If someone is assisting you with the application, it’s vital to formally designate them as an authorized representative within the form. This designation allows them to discuss your application and handle communication with TennCare on your behalf.

Lastly, it’s common for applicants to overlook the need to sign and date the application before submission. An unsigned application will not be processed and could lead to missed deadlines. Always review the entire packet to ensure every necessary section is complete and that signatures are included.

Being aware of these frequent mistakes when filling out the TennCare Renewal Packet can save time and prevent unnecessary frustration. By taking a moment to carefully review the application and ensure all information is accurate and complete, individuals can enhance their chances of successfully receiving the healthcare assistance they need.

Documents used along the form

The TennCare Renewal Packet is an essential document for Tennessee residents seeking to renew their eligibility for long-term services and supports, as well as various Medicare savings programs. Alongside the renewal packet, several other forms and documents are often required to ensure the application process is complete and efficient. Below is a list of those documents.

Proof of Identity: This document serves to verify the identity of the applicant. Acceptable forms can include a driver’s license, state ID card, or a passport. A clear copy is typically required.
Proof of Income: Applicants must provide evidence of their income. This could be recent pay stubs, tax returns, or documentation of Social Security benefits. Copies of these documents should be submitted.
Asset Verification: Individuals need to declare any significant assets they own. This may include property deeds, bank statements, or investment accounts. Proof should reflect current values.
Authorized Representative Form: If someone is assisting the applicant with the application, this form authorizes that person to speak on the applicant's behalf. It must include the representative's contact information and be signed by the applicant.
Proof of Residency: Applicants must demonstrate that they reside in Tennessee. This can be achieved through utility bills, leases, or government correspondence that includes the applicant's name and address.
Medicare Card: If the applicant has Medicare, a copy of the Medicare card is needed to help determine eligibility for Medicare saving programs.

Completing the TennCare renewal process requires careful attention to these documents. Each plays a critical role in ensuring that eligibility is accurately assessed and that applicants receive the necessary assistance. Take time to gather these items before submitting your renewal packet.

Similar forms

Medicaid Application Form: This form is similar as it also collects personal information and proof of income for individuals seeking Medicaid services. Both forms require information about household members and their respective income sources.
Home and Community Based Services (HCBS) Application: Like the TennCare Renewal Packet, this application targets individuals needing services to prevent nursing home placement. It prompts for similar financial details and living situation information.
Medicare Savings Program Application: This form assists those looking for help with Medicare costs. It, too, requires proof of income and residency, focusing on maintaining eligibility for financial support.
Nursing Home Eligibility Application: It is similar in assessing eligibility for nursing home care by gathering personal and financial information. Both require details about current living arrangements and health status.
Long-Term Care Questionnaire: This document evaluates the need for long-term care similar to the TennCare Renewal Packet. Information on current health conditions and financial status is essential in both.
Eligibility Review for Intellectual and Developmental Disabilities Services: This application is comparable as it seeks to determine eligibility for community services based on disability status, including financial and living situation assessments.
Application for Hospice Services: This document requires personal and financial details from individuals seeking hospice care. It identifies similar caregiver support needs and requires proof of income.
Supplemental Security Income (SSI) Application: This application collects information on financial resources and living situations. It's similar in its purpose to assess whether individuals qualify based on their income and assets.

Dos and Don'ts

When filling out the TennCare Renewal Packet form, there are certain best practices to follow for successful completion. Here are some important things to remember:

Provide Accurate Information: Ensure that all personal details, including your name, address, and contact information, are correct. This helps avoid delays.
Include Supporting Documents: Attach any necessary proof of income, residence, or other eligibility requirements as outlined in the application.
Double-Check Your Answers: Review all sections of the form for completeness and accuracy before submitting it. Missing information can lead to rejection.
Submit on Time: Mail or fax your completed application as soon as possible. Delays in submission can affect your benefits.

Conversely, there are pitfalls to avoid during the process:

Do Not Leave Blank Spaces: Fill out every section of the application. If a question does not apply, you should answer with 'N/A' rather than leaving it blank.
Do Not Send Original Documents: Always send copies of documents rather than originals to ensure you retain important paperwork.
Avoid Ambiguous Responses: Provide clear and concise answers. Mixed or unclear responses may lead to confusion or delays in processing.
Do Not Forget to Sign: Remember to sign and date your application before submission. An unsigned application will not be processed.

Misconceptions

The TennCare Renewal Packet form is an essential document for Tennessee residents seeking assistance with healthcare services. However, several misconceptions surround its purpose and requirements. Here is a list of common misunderstandings regarding the TennCare Renewal Packet form:

Only nursing home residents can apply: Many believe that only individuals residing in nursing homes qualify for TennCare. In fact, the program also supports older adults and those with disabilities, regardless of their living situation.
Anyone can be an authorized representative: While authorized representatives can assist applicants, they must be selected carefully. Not just anyone can represent you; this person must be trusted and designated on the application.
I cannot apply if I have Medicare: Some folks think they are ineligible if they already have Medicare coverage. However, TennCare can actually help with Medicare costs for qualified individuals, making the application worthwhile.
My income doesn’t matter: Another misconception is that income is irrelevant when applying for TennCare. On the contrary, providing information about income is crucial, as it helps determine eligibility.
You can keep your out-of-state Medicaid: Some believe they can maintain Medicaid benefits from another state while applying for TennCare. However, one cannot receive TennCare if they are enrolled in Medicaid elsewhere.
The application is only for long-term care: Many people think the form is exclusively for long-term care services. In reality, it also accommodates those seeking help with hospice care and community-based services.
All information needs to be submitted in its original form: A prevalent myth suggests that applicants must provide original documents. Applicants can submit copies of necessary documents, which simplifies the application process.

Understanding these misconceptions can significantly improve the chances of successfully navigating the TennCare renewal process. Correct information allows individuals to receive the healthcare support they need.

Key takeaways

Here are important points to keep in mind when filling out and using the TennCare Renewal Packet form:

Identify the individuals eligible to use the application. It is intended for those in nursing homes, seeking home and community-based services, or needing help with Medicare costs.
Complete the application accurately, including personal information like your name, address, and contact details.
Provide current residency details. You must intend to remain a Tennessee resident and not receive Medicaid from another state.
Designate an authorized representative if someone will assist you with your application. This person's contact information must be included.
Gather and send proof of income, including pay stubs and tax returns. Do not send originals; copies will suffice.
Complete all sections regarding everyone living in your home, even if they are not applying for TennCare.
If you have health insurance, provide details about your policies, including names, policy numbers, and premium amounts.
Clearly outline any assets, including property and financial accounts. Remember, failing to disclose may affect eligibility.
Submit your completed application by mailing it to TennCare Connect or faxing it to the provided number.

Filling out the form thoroughly will enhance your application’s chances of success. Don’t hesitate to reach out for help if needed.

Browse Other Templates

Hoa Proxy Vote Template - The proxy can be a neighbor or a member of the board, as specified on the form.

Daycare Forms - Recommendations for care provision are based on the assessment documented in the form.

Form Col - Don't overlook the application's authority statements and legal considerations.