Tennessee



|[pic] |Tennessee Department of Children’s Services |

| |Subsidized Permanent Guardianship Agreement |

|Funding Source: IVE State |Date of Initial Application |      |

The following Agreement has been entered into by and between: Tennessee Department of Children’s Services

|      | |(   )     -      |

|(Office Street Address) | |(Telephone Number) |

|      | | |

(City, State, Zip)

hereafter called the "Agency", and

|      |      |

(Permanent Guardian(s) full name(s)) (Permanent Guardian Email)

|       | |(   )     -      |

| (Permanent Guardian(s) Street Address) | |(Telephone Number) |

|       | | |

| (City, State, Zip) | |

hereafter called the “Permanent Guardian (s)", for the purpose of facilitating the legal transfer of guardianship of

|      | |      |, a Male Female child, born on |

| (Child’s Name) | | (TFACTS Person ID) | |

|      |, and to aid the family in providing proper care for the child. |

|(Date) | |

This document is the:

| Initial |The prospective Guardian(s) agree that he/she/they intend to accept Permanent Guardianship for |

|Agreement: | |

| |      |and have signed this document prior |

| |(Child's Name) | |

| |to transfer of the Permanent Guardianship for the purpose of receiving Subsidized Permanent Guardianship payments and/or services for |

| |the child from the time of transfer. |

| |

| Revision Agreement: |This is a modification of the Subsidized Permanent Guardianship Agreement for: |

| |      | |

| |(Child’s Name) | |

|whose SPG contract was signed on: |      | |

| |(Date) | |

| | | |

|Reason For Revision: |      |

| |

|Termination: |This is a termination of the Subsidized Permanent Guardianship Agreement for: |

| |      |      |

| |(Child’s Name) |( Date) |

| | |

|Reason For Termination: |      |

PROVISIONS OF AGREEMENT

I. Assistance

A. Nonrecurring Subsidized Permanent Guardianship Expenses

(List specific service and cost of each; total not to exceed $2000)

|      | for |       |

|(service) | | (amount) |

|      | for |       |

|(service) | | (amount) |

|      | for |       |

|(service) | | (amount) |

B. Payment

Note: All payments hereunder are subject to both state and federal funding

In accordance with the Department of Children’s Services’ foster care rate structure, Subsidized Permanent Guardianship payments will be paid based on a daily rate for the number of days for the current month.

| |

|      |

|will receive |

|$       |

|per day effective |

|      |

| |

|(Child’s Name) |

| |

|($ amount) |

| |

|(Date) |

| |

|The amount of this payment (Subsidized Permanent Guardianship) is based on the needs of the child and the circumstances of the Permanent Guardian(s) and|

|has been determined by mutual agreement between the Permanent Guardian(s) and the agency. The amount of the payment does not exceed the foster |

|care payment for |      |if he/she were in a foster family home |

| |(Child’s Name) | |

|in the State of Tennessee. |

Such payments shall not exceed the Department of Children’s Services foster care board rate. Subsidized Permanent Guardianship payments shall terminate when the IV-E child reaches their 21st birthday.

C. Successor Guardian

In the event that the Guardian becomes incapacitated or dies, a Successor to the Guardianship Subsidy payment can be identified. If a Successor is not identified on this agreement, a person can be identified during future renewals or revisions.

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(Successor Guardian’s full name(s))

|      |

|(Successor Guardian(s)’s Address) |

| |

     

|(Successor Guardian(s)’s Email Address |

     

|(Successor Guardian(s)’s telephone number) |

D. Medical, Psychological/Psychiatric, Dental, Hospitalization, Residential Care and Other Expenses.

1. The State of Tennessee will not make payments for medical, psychological/psychiatric, dental, hospital, residential care or for other expenses that exceed the terms of this agreement.

2. Children receiving IV-E Subsidized Permanent Guardianship payments are categorically eligible for Title XIX Medicaid. Benefits as provided under Title XIX of the Social Security Act (which is known in Tennessee as TennCare) are provided to Title IV-E SPG children. Benefits as provided under Title XIX of the Social Security Act may be available to State-Funded children in accordance

| with the Title XIX Medicaid eligibility procedures of the state in which |      |resides. |

| |(Child's Name) | |

3. If the child is not eligible for TennCare/Medicaid or its successor plan regardless of the State

| in which |       |lives and the child is ineligible for private insurance, |

| | (Child's Name) | |

| payments will be provided by the State of Tennessee for: |

a. Medical services related to the following conditions:

| |      |

(Specify)

| | at an amount per the current TennCare/Medicaid or its successor rates beginning |

| | |Enter Effective Date |

| | (Effective Date) |(Effective Date) |

b. Psychological/psychiatric services related to the following conditions:

| |      |

| |(Specify) |

| | at an amount per the current TennCare/Medicaid or its successor rates beginning |

| | Finalization |Enter Effective Date |

| | (Effective Date) |(Effective Date) |

c. Dental services related to the following conditions:

| |      |

(Specify)

| | at an amount per the current TennCare/Medicaid or its successor rates beginning |

| | Finalization |Enter Effective Date |

| | (Effective Date) |(Effective Date) |

d. Hospitalization/residential treatment related to the following conditions:

| |      |

(Specify)

| | at an amount per the current TennCare/Medicaid or its successor rates beginning |

| | Finalization |Enter Effective Date |

| |(Effective Date) |(Effective Date) |

e. Other expenses as follows:

| |      |

(Specify)

| | at an amount per the current TennCare/Medicaid or its successor rates beginning |

| | Finalization |Enter Effective Date |

| |(Effective Date) |(Effective Date) |

4. Procedures for meeting the costs of medical, psychological/ psychiatric, dental, hospital, residential, or other special care or expenses shall consist of the following:

a. Insurance coverage through the guardian(s)’s insurance policy, if available, must be utilized first to provide for the services the child needs as detailed above.

b. If private insurance coverage is not available, TennCare will be utilized for all covered services to children who are enrolled in TennCare.

c. TennCare (Medicaid) coverage for all types of care will be utilized whenever available whether the child lives in Tennessee or resides in another state. The TennCare (Medicaid) rate for hospitalization will be the maximum rate paid for the child who is TennCare (Medicaid) eligible when services are provided by a TennCare (Medicaid) provider.

d. Care for children residing in Tennessee, consistent with Federal law, shall be covered by any successor plan to TennCare, if the child is eligible for such program.

e. If the child is ineligible for TennCare or its successor plan and the child is ineligible for private insurance, the rates shall be established for all Subsidized Permanent Guardianship children residing in the State of Tennessee as provided below:

(i) If the State of Tennessee has a contract with a provider of services for children in the State's custody, that contract rate shall be utilized in providing care for the child, whether the child resides in or out of the State of Tennessee.

(ii) If the provider is not under contract with the State, the State shall pay the usual and customary rate as defined in departmental policy.

f. Children Residing Outside the State of Tennessee or the United States Not Covered by Private Insurance, Medicaid or its successor plans, or other governmental coverages:

When the child is not TennCare eligible, is ineligible for private insurance, or is not eligible for coverage under any government sponsored care, and the child resides outside the State of Tennessee or the United States, out-of-state or out of country, care will be paid at the usual and customary rate as defined in departmental policy.

g. If, after establishment of a "usual and customary rate" for the provider chosen by the guardian(s), that rate is no longer sufficient or will not meet the child's needs, the guardian(s)shall report this circumstance to the Central Office Subsidy Unit and the State shall further negotiate the rate, which

shall be determined at the sole discretion of the State, for services with the provider.

h. The State shall not supplement payments made under private insurance; nor shall it pay any co-payments or deductibles required under private insurance.

i. If the child is ineligible for TennCare and is ineligible for private insurance and the guardian(s) feel that the child needs out-of-state placement for services for therapeutic reasons, the guardian(s) must first consult with the Central Office Subsidy Unit and must first provide such documentation or

any other information as may be required by the Department to adequately demonstrate the

reasons requiring placement in an out-of-state program or facility. The guardian(s) must receive

approval prior to out-of-state placement of the child before payment for the services will be

made by the State of Tennessee.

j. Approval of Residential Treatment for children who are ineligible for TennCare and are ineligible for private insurance:

(i) All residential treatment placements shall be approved in writing by the Program Director of Foster Care and Adoption prior to the child’s placement.

(ii) Children residing in Tennessee shall be placed in a State contracted facility with the State contracted rate unless exceptional circumstances apply which make out-of-state treatment necessary.

(iii) For children residing outside of Tennessee, residential rates within their state of residence shall be explored and appropriate rates negotiated.

k. It is expressly understood and agreed that there shall be no payment by the State of Tennessee for services or for portions of services covered by any insurance available to the child or to the guardian(s). Services covered by government sponsored programs in other states or countries for which the child or guardian(s) may be eligible and which do not have specific exclusions or reimbursement requirements for the coverages shall not be reimbursed by the State of Tennessee to the guardian(s) or the sponsoring government.

l. If the child is ineligible for TennCare and is ineligible for private insurance and the guardian(s) must make payments for services, they shall submit to the state documentation showing such payments. They shall be reimbursed for those costs subject to all requirements in Paragraph C.4.

D. Families approved for Subsidized Permanent Guardianship in Tennessee who live out-of-state should adhere to the following procedures for receipt of Subsidized Permanent Guardianship, medical care and social services:

1. Subsidized Permanent Guardianship payments will continue to be received from Tennessee.

2. Payments for services shall be made under the provisions of Paragraph C.4.

3. After finalization, if the guardian(s) lives or moves to another state, the Department of Children's Services will make a referral to the new state of residence to ensure that medical coverage continues, as provided through the Interstate Compact on Adoption and Medical Assistance (ICAMA).

II. Notification of Change

A. The Permanent Guardian(s) will immediately notify the agency (DCS subsidy staff responsible for managing the guardianship assistance agreement), in writing, if they are no longer legally responsible for the support of the child or are no longer supporting the child. (For example, the guardian(s) have surrendered their guardianship, the child has married or gone into the military or has left the home and the parents provide no support for the child.).

B. The Department shall be notified as soon as possible if the Permanent Guardian becomes incapacitated or dies.

C. The guardian(s) will immediately notify the agency (DCS subsidy staff responsible for managing the guardianship assistance agreement) if the child is no longer residing with the guardian(s) in the guardianship home.

D. The guardian(s) will immediately notify the agency (DCS subsidy staff responsible for managing the guardianship assistance agreement) if the child enters or exits foster care.

E. The guardian(s) will immediately notify the agency (DCS subsidy staff responsible for managing the guardianship assistance agreement) when youth is approved for Extension to Foster Care (EFC) program.

F. The agency will notify the Permanent Guardian(s) in writing of changes in Subsidized Permanent Guardianship payments resulting from increases or decreases in Subsidized Permanent Guardianship rate.

G. The Permanent Guardian(s) will notify the agency (DCS subsidy staff responsible for managing the guardianship assistance agreement) of changes of residential or mailing address.

H. The Permanent Guardian(s) will notify the agency (DCS subsidy staff responsible for managing the guardianship assistance agreement) if there is a change in the child’s treatment needs that would warrant an increase or decrease to the Subsidized Permanent Guardianship payment.

I. The Permanent Guardian(s) will notify the agency (DCS subsidy staff responsible for managing the guardianship assistance agreement) immediately upon being made payee for SSA or VA benefits on behalf of the child as well as any changes in the amount of those benefits. Any payments and/or retroactive payments from SSA or VA benefits must be adjusted against the Subsidized Permanent Guardianship payment for State Funded Agreements only. The family will be responsible for making repayments of any Subsidized Permanent Guardianship paid in error.

J. The guardian(s) will provide documentation prior to a child’s 18th birthday to establish continuing eligibility for Subsidized Permanent Guardianship. This documentation must be provided each year the child remains eligible for SPG past the age of 18. The case will be closed if appropriate documentation is not provided.

K. Children receiving a regular or special circumstances rate may be eligible for an increase in the daily rate once the child reaches age 12. The guardian(s) are expected to notify the agency (DCS subsidy staff responsible for managing the guardianship assistance agreement) and request the increase prior to the child’s 12th birthday. Retroactive payments will not be made for cases where the guardian(s) request an increase after the child’s 12th birthday. The effective date for the increase will be the 1st day of the following month in which the guardian(s) made the request for the increase.

L. The guardian(s) will notify the agency (DCS subsidy staff responsible for managing the guardianship assistance agreement) when a IV-E funded child/youth who entered the Subsidized Permanent Guardianship program on or after October 1, 2010 and were at least age 16 at the time the agreement was made, turns 21 years old or graduates from high school or an approved post-secondary or vocational program, whichever occurs first.

M. The guardian(s) will notify the agency (DCS subsidy staff responsible for managing the guardianship assistance agreement) when a IV-E funded child/youth who entered the Subsidized Permanent Guardianship program on or after October 1, 2010 and were at least age 16 at the time the agreement was made, becomes capable of employment or attending school if the child has previously been identified my a medical professional as being incapable of employment or attending school.

N. The guardian(s) will notify the agency (DCS subsidy staff responsible for managing the guardianship assistance agreement) when a State-funded child/youth who entered the Subsidized Permanent Guardianship program on or after October 1, 2010 and were at least age 16 at the time the agreement was made, turns 19 years old or graduates from high school, whichever occurs first.

O. The guardian(s) will notify the agency (DCS subsidy staff responsible for managing the guardianship assistance agreement) when a child/youth who entered the Subsidized Permanent Guardianship program prior to October 1, 2010 turns 19 years old or graduates from high school, whichever occurs first.

P. The month prior to a youth’s 21st birthday, the guardian(s) must notify the agency (DCS subsidy staff responsible for managing the guardianship assistance agreement) of the child’s impending birthday. Any payment received on or after the youth’s 21st birthday must be repaid.

Q. Permanent Guardian’s failure to notify the agency (DCS subsidy staff responsible for managing the guardianship assistance agreement) of any changes affecting the child’s eligibility for Subsidized Permanent Guardianship or the child’s daily rate resulting in overpayments will require repayment of the total amount of the Subsidized Permanent Guardianship overpayment. The Department will take diligent action to recover any overpayment, including but not limited to legal action.

III. Renewal Agreement

A. This Agreement is renewed periodically by the Permanent Guardian(s) and the State agency for those that receive state-funded Subsidized Permanent Guardianship.

B. Any family who receives Subsidized Permanent Guardianship will have their agreement reviewed at the time of the child’s 18th birthday to determine continued eligibility.

C. The Permanent Guardian(s) will provide documentation to establish continuing eligibility for Subsidized Permanent Guardianship periodically during the renewal process. The subsidy will be terminated if required documentation is not provided. (State Funded Agreements only).

D. The agency shall notify the Permanent Guardian(s), in writing, 60days before the need for renewal and shall supply the Permanent Guardian(s) with the appropriate forms.

E. A second notice will be sent by certified mail 30 days after the initial request.

IV. Revision Agreement

A. Subsidized Permanent Guardianship may be revised at any point after approval when there is a change in circumstances (i.e. child re-enters care or there is a need to identify or access a Successor Guardian).

B. Effective dates for any revision will be the first day of the month following completion and approval of the revision agreement. All revisions to the subsidy rate must begin the first day of the month and end the last day of the month.

C. Children receiving a regular or special circumstances rate may be eligible for an increase in the daily rate once the child reaches age 12. The guardian(s) are expected to notify the agency and request the increase prior to the child’s 12th birthday. Retroactive payments will not be made for cases where the guardian(s) request an increase after the child’s 12th birthday. The effective date for the increase will be the 1st day of the following month in which the guardian(s) made the request for the increase.

D. All revised agreements shall supersede and replace any and all previous agreements between the Department of Children’s Services and the guardianship parent(s).

E. DCS reserves the right to revise/modify, make corrections or terminate the guardianship assistance agreement due to error or oversight concerning the eligibility for the guardianship assistance program, the funding source, the guardianship assistance rate, content in the guardianship assistance agreement, or changes made in DCS administrative guardianship assistance policy, rules or regulation which govern the guardianship assistance program.

V. Termination

Termination will occur in any of the following circumstances:

A. Upon the conclusion of the terms of the Agreement;

B. Upon the request of the Permanent Guardian(s);

C. If the Permanent Guardian(s) legal responsibility to the child ends;

D. If DCS determines the child is no longer receiving financial support from the permanent guardian(s).

E. If the child marries;

F. If the child enlists in the military;

G. If the youth is approved for and begins receiving benefits from the Extension to Foster Care (EFC) program;

H. If the agency determines that a child was made eligible for the guardianship assistance program in error, DCS reserves the right to terminate the guardianship assistance agreement due to error or oversight concerning the determination of eligibility for the guardianship assistance program.

I. If the child dies;

J. If the Permanent Guardian(s) dies, or becomes incapacitated;

K. If DCS determines that the family fails to complete the renewal/revision process within the time frames outlined in the Subsidized Permanent Guardianship agreement. (State funded agreements only).

□ Subsidized Permanent Guardianship Agreements made on or after October 1, 2010 for IV-E funded children who were at least age 16 at the time the agreement was made, will end at the age of 21 or graduates from high school or an approved secondary program.

□ Subsidized Permanent Guardianship Agreements made on or after October 1, 2010 for IV-E funded children who were at least age 16 at the time the agreement was made, will end at the age of 21 or graduates from an institution, which provides post-secondary or vocational education.

□ Subsidized Permanent Guardianship Agreements made on or after October 1, 2010 for IV-E funded children who were at least age 16 at the time the agreement was made, will end at the age of 21 or when or if the child becomes capable of participating in employment or attending school (if the child has previously been identified by a medical professional as being incapable of employment or attending school), whichever occurs first.

□ Subsidized Permanent Guardianship Agreements made after October 1, 2010 for State-funded children who were at least 16 at the time the agreement was made will end once the child turns 19 or graduates from high school, whichever occurs first.

□ Subsidized Permanent Guardianship Agreements made prior to October 1, 2010 regardless of funding source will end once the child turns 19 or graduates from high school, whichever occurs first.

□ For Title IV-E children, Subsidized Permanent Guardianship will be provided until the child is 21 years of age if the child has a documented mental or physical disability which warrants continuation of Subsidized Permanent Guardianship after the child turns 18.

□ If a youth has been determined eligible for continuation of State Funded or Title IV-E Subsidized Permanent Guardianship beyond the youth’s 18th birthday due to school enrollment, the youth must maintain continual full time school enrollment and attendance. Breaks in full time attendance and enrollment will disqualify the youth for continued eligibility. The only exception is in instances where the educational institution considers the break to be normal or customary for the school year.

L. All state-funded Subsidized Permanent Guardianship agreements hereunder are subject to funding.

VI. Appeal

Permanent Guardian(s) may appeal the agency's decision to deny, terminate or change their child’s Subsidized Permanent Guardianship in accordance with rules and procedures of the State's fair hearing and appeal process. Permanent Guardian(s) must appeal an adverse decision within ten (10) business days of written notice of adverse action. Subsidized Permanent Guardianship may continue pending the determination of an appeal. If adverse action is upheld during an appeal, payments continued during the appeal period will be considered an overpayment and will be subject to recovery. The following are the steps of the appeals process:

A. If the DCS determines that Subsidized Permanent Guardianship will be denied, terminated, or changed, the Permanency Specialist or Subsidy Specialist must notify the foster family immediately, in writing, utilizing a Notice of Denial Termination, or Change in Subsidized Permanent Guardianship letter, CS-0720. An Appeal for Fair Hearing, form CS-0403 must also be given to the Permanent Guardian(s) at that time.

B. Form CS-0720, Notice of Denial Termination, or Change in Subsidized Permanent Guardianship,. must be dated with the same date it is mailed or, if hand delivered, the date it is hand delivered to the guardian(s).

C. Upon request, DCS must also provide the Administrative Procedures Division with a copy of all notification documents that were provided to the family.

D. DCS must inform the guardian(s) about the timeframe in which they have to file an appeal. DCS must also provide the fax number and the mailing address to which the Appeal for Fair Hearing, form CS-0403, must be sent.

E. The Administrative Procedures Division will notify the appropriate county office if an appeal of Subsidized Permanent Guardianship is received. Once notified by the Administrative Procedures Division, the county must follow the direction of that office to ensure due process protocol is followed.

F. DCS staff must complete an appeal summary as directed by the Administrative Procedures Division.

G. Additional information may be accessed by contacting the TN DCS Administrative Procedures Division at:

Plaza Tower – Metro Center

200 Athens Way, 2nd Floor, Suite B

Nashville, TN 37243 or 37228 – Using Fed Ex or UPS

Phone: 615-741-1110

Fax: 615-741-4518

VII. Payment and Service Transfer

This Agreement shall remain in effect regardless of the State of which the guardian(s) are living at any given time. Post Permanency Service availability may vary based upon the child’s state of residence.

VIII. Post-Permanency Services

Tennessee Adoption Support and Preservation (ASAP) is a collaborative program including Harmony Family Center and Catholic Charities of Tennessee, Inc.

ASAP assists families in accessing services that support permanency by offering case management and referral-based services, support groups for guardians and children, psycho-educational and collaborative learning opportunities and they ensure these services are individualized to meet the needs of each family they serve.

Any family who finalized guardianship of a child formerly in the custody of Tennessee Department of Children’s Services that is currently 18 years of age or younger is eligible to receive these services.

Families may directly contact the ASAP hotline to get started at 1-888-848-2727 or visit the ASAP website at .

Note: Post Permanency Services are subject to funding availability.

Services to support relative (blood, marriage or adoption) guardians and the child can be provided by the Relative Caregiver Program.

• Shelby Region (901) 448-3133 UT Boling Center for Developmental Disabilities

• Knox, East, Smoky & Northeast Regions (865) 376-3464 Omni Community Health

• Davidson Region (615) 320-0591 Family & Children’s Service

• Tennessee Valley Region (423) 424-4281 S. East Tennessee Area Agency on Aging & Disability

• Upper Cumberland Region (931) 432-4111 Upper Cumberland Development District

• Northwest & Southwest Region (731) 772-8378 Exchange Club-Carl Perkins Center

• South Central Region (931) 684-4676 The Center for Family Development

• Mid-Cumberland Region (615) 445-8711New Visions Inc.

IX. Independent Living Services for Youth who entered Guardianship at age 16 Years or Older

Youth who exited state custody at age 16 or older to guardianship may be eligible for Independent Living

Wraparound funding. This funding is established as a resource to support the provision of certain

Independent Living Services for eligible youth and young adults.

Youth who exit state custody at age 16 or older to guardianship are also eligible for an Education and

Training Voucher (ETVs). ETVs are only utilized to fund expenses for eligible post-secondary institutions.

The Education and Training Voucher may provide up to $2500 semester/up to $5000 per year.

Please contact the Office of Independent Living at 615-253-3503 or email

EI_DCS_Independent_Living_Referral@ to learn more about the services the youth may be eligible for.

|NOTE: |Payments identified in the Subsidized Permanent Guardianship Agreement between the Tennessee |

| |Department of Children’s Services and |     |will not |

| | |(Permanent Guardian(s) Name) | |

| |be made prior to the "effective date". The effective date cannot be before the transfer of guardianship on this contract. This agreement |

| |must contain the signatures of the Permanent Guardian(s) and the appropriate DCS representatives in order to be a valid agreement. |

| | | |      |

| |Permanent Guardian’s Signature | |(Date) |

| | | |      |

| |Permanent Guardian’s Signature | |(Date) |

Signed copy of the Subsidized Permanent Guardianship Agreement given/sent to Permanent Guardian(s) on

|      |. |

|(Date document was provided to the family) | |

|Initial Approval: | | | |      |

| | |Authorized Agency Representative's Signature | |(Date) |

| | |(Permanency Specialist) | | |

| | | | |      |

| | |DCS Team Leader | |(Date) |

|Revision/Termination: | | | |      |

| | |Subsidy Specialist | |(Date) |

|Revision/Termination Approval: | | | | |

| | | | |      |

| | |Authorized Agency Representative's Signature | |(Date) |

| | |(Subsidy Specialist’s Team Leader) | | |

|Effective date for Subsidized Permanent Guardianship: | | |

| |Finalization |Enter Actual Finalization Date |

| | |(Effective Date) |

|Was the Guardianship finalization verified? | |     /     /      |

| |DCS Representative Signature |(Date of Signature) |

| |(Denotes Verification) | |

| | | |

|The next renewal date for state funded subsidy is: |     /     /      |

IV-E funded subsidies will be reviewed at the child/youth’s 18th birthday. _____________________________________________

Date

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