The Following Agreement Has Been Entered Into by and Between

94947 / Tennessee Department of Children’s Services
Adoption Assistance Agreement
Date of Initial Application: / //
Funding Source: IVE State Fostering Connections IV-E
AA Category: Active Deferred

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

(Adoptive/Adopting Parent(s) full name(s)) (Email Address)

() -
(Street Address Adoptive/Adopting Parent[s]) / (Telephone Number)

(City/State/Zip)

hereafter called the "Adoptive Parent(s)", for the purpose of facilitating the legal adoption of

, a Male Female child, born on
(Child’s adoptive name) (TFACTS Person ID)
, and to aid the adoptive family in providing proper care for the child.
(date)

This document is the:

Initial Agreement: / The prospective adoptive parent(s) agree that he/she/they intend to adopt
and have signed this document prior
(Child's Adoptive Name)
to finalization of the adoption for the purposes of receiving Adoption Assistance payments and/or services for the child from the time of finalization.
Revision Agreement: / This is a revision of the Adoption Assistance Agreement for
whose adoption was finalized on
(Child's Adoptive Name)
(date)
Reason For Revision:
Termination: / This is a termination of the Adoption Assistance Agreement for
(Child's Adoptive Name)
Reason for Termination

PROVISIONS OF AGREEMENT

I.Assistance

A.Nonrecurring Adoption Expenses

(list specific service and cost of each)

and / $
(amount) / (amount)
and / $
(amount) / (amount)
and / $
(amount) / (amount)
and / $
(amount) / (amount)

B.Payment

In accordance with the Department of Children’s Services’ foster care rate structure, Adoption Assistance 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 Adoptive Name) / ($ amount) / (Date)
The amount of this payment (Adoption Assistance) is based on the needs of the child and the circumstances of the adoptive parent(s) and has been determined by mutual agreement between the adoptive parent(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 adoptive name)
in the State of Tennessee.

Such payments shall not exceed the Department of Children’s Services foster care board rate. Adjustments in payments may be made with the concurrence of the adoptive parent(s) and the State

of Tennessee based upon changes in the needs of / ,
(Child's adoptive name)

Documentation of changes in the child's needs or family's circumstances shall be required.

C.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. Benefits as provided under Title XIX of the Social Security Act (which is known in Tennessee as

TennCare) may be available to Title IV-E children and to state-funded children in accordance
with the procedures of the state in which / resides.
(Child's adoptive 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
(Child's adoptive name)
private insurance, then payments will be provided by the State of Tennessee for:

1. medical services related to the following conditions:

(Specify)

at an amount per the current TennCare/Medicaid or its successor rates beginning
Finalization / Enter Actual Finalization 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 Actual Finalization 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 Actual Finalization 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 Actual Finalization 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 Actual Finalization 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:

1. Insurance coverage through the adoptive parent(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 Adoption Assistance 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 adoptive parent(s), that rate is no longer sufficient or will not meet the child's needs, the adoptive parent(s) shall report this circumstance to the Department of Children’s Services, 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 adoptive parent(s) feel that the child needs out-of-state placement for services for therapeutic reasons, the adoptive parent(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 adoptive

parent(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 adoptive parent(s). Services covered by government sponsored programs in other states or countries for which the child or adoptive parent(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 adoptive parent(s) or the sponsoring government.

l.If the child is ineligible for TennCare and is ineligible for private insurance and the adoptive parent 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 Adoption Assistance in Tennessee who live out-of-state should adhere to the following procedures for receipt of Adoption Assistance, medical care and social services:

1.Adoption Assistance 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 adoptive family 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 adoptive parent(s) will immediately notify the agency, 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 adoptive parent(s) have

surrendered their parental rights, 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 adoptive parent(s) will immediately notify the agency (DCS subsidy staff responsible for managing the

adoption assistance agreement) when the child is no longer residing with the adoptive parent(s) in the adoptive home.

C. The adoptive parent(s) will immediately notify the agency (DCS subsidy staff responsible for managing the

adoption assistance agreement) if the child enters or exits foster care.

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

E.The agency will notify the adoptive parent(s) in writing of changes in Adoption Assistance payments resulting

from increases or decreases in Adoption Assistance rates.

F. The adoptive parent(s) will notify the agency (DCS subsidy staff responsible for managing the

adoption assistance agreement) of changes of address in writing to the Central Office

Subsidy staff.

G. The adoptive parent(s) will notify the agency (DCS subsidy staff responsible for managing the adoption 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 retro-active payment from SSA or VA benefits must be adjusted against the adoption assistance payment for State Funded Agreements only. The adoptive family will be responsible for making repayment of any adoption assistance paid in error.

1. The adoptive parent(s) will provide documentation prior to a child’s 18th birthday to establish continuing eligibility for ongoing adoption assistance. This documentation must be provided each year the child remains eligible for Adoption Assistance past the age of 18. The case will be closed if appropriate documentation is not provided within the requested time frame as established by DCS.

1. The adoptive parent (s) will notify the agency (DCS subsidy staff responsible for managing the adoption assistance agreement) when a child/youth adopted on or after October 1, 2010 who has been determined Fostering Connections IV-E eligible, graduates from an institution which provides post-secondary or vocational education graduates from high school, or turns age 21, whichever comes first.

1. The adoptive parent(s) will notify the agency (DCS subsidy staff responsible for managing the adoption assistance agreement) when a child/youth adopted on or after October 1, 2010, who has been determined Fostering Connections IV-E eligible, becomes capable of employment or attending school if the child has previously been identified by a medical professional as being incapable of employment or attending school.

1. The month prior to a youth’s 21st birthday, the adoptive parents must notify the Department of the child’s impending birthday. Any payment received on or after the youth’s 21st birthday must be repaid.

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

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

III.Renewal Agreement

1. This Agreement is renewed periodicallyby the adoptive parent(s) and the State agency for those that receive state-funded Adoption Assistance.

1. Any family that receives an Adoption Assistance subsidy will have their Agreement reviewed at the time of the child’s 18th birthday to determine continued eligibility.

1. The adoptive parent(s) will provide documentation to establish continuing eligibility for state funded Adoption Assistance periodically during the renewal process. The case will be terminated if required documentation is not provided.

1. The agency shall notify the adoptive parent(s), in writing, 60 days before the need for renewal and shall supply the adoptive parent(s) with the appropriate forms.

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

1. The adoption assistance agreement will be considered for termination if sufficient information is not received by the due date.

IV.Revision Agreement

A. Adoption Assistance may be revised at any point after approval when there is a change

in circumstances (i.e., child re-enters care).

B. All revisions to the subsidy rate must begin the first day of the month and end the last day of the month.

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

1. Adoption Assistance benefits or the time frame in which the child remains eligible for the adoption assistance program, are subject to guidelines set forth in the revised agreement and in the DCS policies, rules, and regulations, which govern the adoption assistance program.

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

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

V.Termination

Termination will occur in any of the following circumstances:

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

1. Upon request of the adoptive parent(s);

1. If the adoptive parent(s)’s legal responsibility to the child ends;

1. If the department determines that the adoptive family is not financially supporting the child/youth.

1. If the child marries;

1. If the child enlists in military service;

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

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

1. A youth approved for Deferred Adoption Assistance turns 18 years old.

J. If the child dies;

K. If the adoptive parent(s) dies;

L. If the Department of Children’s Services determines that the family fails to complete the

renewal renegotiation (for state funded agreements only), or review process within timeframes outlined in the

Adoption Assistance Agreement, policy, procedure or written requests from DCS:

State funded children who were adopted before October 1, 1997 can continue to receive Adoption Assistance as long as they attend any accredited school full time. School attendance must be documented yearly.