1200-13-01-.02 - [Effective until 5/19/2021]DEFINITIONS

1200-13-01-.02. [Effective until 5/19/2021]DEFINITIONS

(1) Activities of Daily Living (ADLs).

(a) Routine self-care tasks that people typically perform independently on a daily basis. One of the components of Level of Care eligibility for LTSS is a person's ability to independently perform (or the amount of assistance needed to perform) certain ADLs, such as:

1. Personal hygiene and grooming;

2. Dressing and undressing;

3. Self-feeding;

4. Functional transfers (getting into and out of bed or wheelchair, getting onto or off toilet, etc.);

5. Bowel and bladder management; and

6 .Ambulation (walking with or without use of an assistive device, e.g., walker, cane or crutches; or using a wheelchair).

(b) For purposes of Katie Beckett Medical (Level of Care) eligibility as described in 1200-13-01-.11, ADLs shall include only the following:

1. Bathing: The ability to shower, bathe or take sponge baths for the purpose of maintaining adequate hygiene (does not include hair care). For older children (over 12 years of age), this also includes the ability to get in and out of the bathtub, turn faucets on and off, regulate water temperature, wash and dry fully.

2. Grooming: The ability to brush teeth, and wash hands and face. Due to variations in hair care by culture, length of hair, etc., hair care is not to be considered.

3. Dressing: The ability to dress as necessary. This does not include the fine motor coordination for buttons and zippers.

4. Eating: The ability to eat and drink by finger feeding or the use of routine or adaptive utensils. The ability to swallow sufficiently to obtain adequate oral intake. This does not include cooking food or preparing it for consumption such as cutting food into bite size pieces or pureeing it.

5. Toileting: The ability to use a toilet or urinal, transferring on/off a toilet, changing menstrual pads, and pulling pants up/down.

6. Mobility: The ability to move between locations in the individual's living environment. For children, this includes home and school. Mobility includes walking, crawling, or wheeling oneself around at home or at school. For purposes of medical (level of care) eligibility for children, mobility does not include transporting oneself between buildings or moving long distances outdoors.

(2) Adult Care Home. For purposes of CHOICES:

(a) A CBRA licensed by the DOH (see Rule 1200-08-36) that offers twenty-four (24) hour residential care and support in a single family residence to no more than five (5) elderly or disabled adults who meet NF LOC, but who prefer to receive care in the community in a smaller, home-like setting. The provider must either live on-site in the home, or hire a resident manager who lives on-site so that the person primarily responsible for delivering care on a day-to-day basis is living in the home with the individuals for whom he is providing care.

(b) Coverage shall not include the costs of Room and Board.

(c) Pursuant to State law, licensure is currently limited to Critical Adult Care Homes for persons who are ventilator dependent or adults with traumatic brain injury.

(3) Adult Day Care.

(a) Community-based group programs of care lasting more than three (3) hours per day but less than twenty-four (24) hours per day and delivered in an Adult Day Care facility permanently licensed by DHS or a Mental Retardation Adult Habilitation Day Facility licensed by DMH, or as of July 1, 2012, by DIDD.

(b) Services shall be provided pursuant to an individualized POC by a licensed provider not related to the participating adult.

(c) The provider shall be responsible for the provision of all assistance and supervision required by program participants. Such assistance is a component of the Adult Day Care benefit and shall not be billed as a separate HCBS.

(4) Adult Dental Services. For purposes of ECF CHOICES only and limited to adults age 21 or older:

(a) Preventive dental services, fillings, root canals, extractions, periodontics, the provision of dentures, and other dental treatments to relieve pain and infection which have dental procedure codes listed in the current TennCare Maximum Reimbursement Rate Schedule for Dental Services that is used specifically for adult dental services provided under the State's Section 1915(c) Waivers for individuals with intellectual disabilities; and intravenous sedation or other anesthesia services provided in the dentist's office by, and billed by, the dentist or by a nurse anesthetist or anesthesiologist who meets the Waiver provider qualifications. Orthodontic services are excluded from coverage.

(b) Dental services for adults age 21 or older enrolled in the ECF CHOICES program shall be reimbursed only for dates of services when the ECF CHOICES Member was enrolled in ECF CHOICES at the time the service was delivered, and subject to the amount approved for such services in the ECF CHOICES Member's PCSP.

(c) All Dental Services for children enrolled in the Waiver are provided through the TennCare EPSDT program. Dental Services shall not be covered through ECF CHOICES for children under age 21 years enrolled in ECF CHOICES (since it would duplicate TennCare/EPSDT benefits).

(d) Adult Dental Services for adults age 21 or older enrolled in ECF CHOICES shall be limited to a maximum of $5, 000 per member per calendar year, and a maximum of $7, 500 per member across three (3) consecutive calendar years.

(5) Aging Caregiver. Pursuant to T.C.A § 33-5-112 as amended, the older custodial parent or custodial caregiver of an individual who has an intellectual disability and who is at least 75 years of age. A Potential Applicant for ECF CHOICES who has an Aging Caregiver shall, subject to all applicable eligibility and enrollment criteria, be enrolled into ECF CHOICES Group 5, unless the Applicant qualifies and elects to enroll in an available ECF CHOICES Group 4 slot, or cannot be safely served in ECF CHOICES Group 5 and meets eligibility criteria, including NF LOC, to enroll in an available ECF CHOICES Group 6 slot. Reserve capacity shall be established in ECF CHOICES Group 5 based on the number of persons with an intellectual disability who have an Aging Caregiver that are expected to be served in each program year.

(6) Applicant. A person applying for TennCare-reimbursed LTSS, for whom a PAE has been submitted to TennCare, and/or by or on behalf of whom a Medicaid application has been submitted to TennCare. An Applicant is entitled to a determination regarding his or her eligibility to enroll in the program for which the PAE has been submitted, and to due process, including notice and the right to request a fair hearing, if the application is denied. For purposes of compliance with the Linton Order, the term shall include all individuals who have affirmatively expressed an intent to be considered for current or future admission to a NF or requested that their name be entered on any NF "wait list." All individuals who contact a NF to casually inquire about the facility's services or admissions policies shall be informed by the facility of that individual's right to apply for admission and be considered for admission on a nondiscriminatory basis and in conformance with Rule 1200-13-01-.06.

(7) Area Agencies on Aging and Disability (AAAD). Agencies designated by the Commission on Aging and Disability or its successor organization to plan for and provide services to the elderly and disabled within a defined geographic area as provided by T.C.A. Title 71, Chapter 2.

(8) Arlington ID Waiver. HCBS Waiver for persons with ID under Section 1915(c) of the Social Security Act (limited to members of the Arlington class certified in United States v. Tennessee, et al.).

(9) Assistance with Premium Payments. For purposes of the Katie Beckett Program only and limited to children enrolled in Katie Beckett Group Part A or Medicaid Diversion Group Part B as follows:

(a) Reimbursement to assist with the cost of the eligible child's portion only of third party liability insurance (TPL) coverage, such as employer-sponsored or other private health insurance:

1. Limited to the amount determined to be the child's portion of TPL coverage premiums, when other family members are also covered by the same premium, calculated by dividing the total premium amount by the total number of family members covered under the policy.

2. Paid only upon proof of payment of the child's premium for the applicable period.

(b) For a child enrolled in Medicaid Diversion Group Part B, the amount that may be reimbursed shall be limited to the amount specified in the child's approved ISP.

(c) May be offered to a child in Katie Beckett Group Part A only if a hardship exception to the requirement to obtain/maintain TPL, as set out in Rule 1200-13-20-.08(8), is requested and would otherwise be approved. In such cases, the Assistance with Premium Payments shall be limited to the amount by which the child's portion of the family's monthly TPL premium exceeds the Katie Beckett Group Part A premium and shall not count against the $15, 000 per calendar year expenditure cap for Katie Beckett Group Part A wraparound HCBS.

(10) Assisted Care Living Facility (ACLF) Services.

(a) CBRA to NF care in an ACLF licensed by the DOH pursuant to Rule 1200-08-25 that provides and/or arranges for daily meals, personal care, homemaker and other supportive services or health care including medication oversight (to the extent permitted under State law), in a home-like environment to persons who need assistance with ADLs.

(b) Coverage shall not include the costs of Room and Board.

(11) Assistive Technology.

(a) For purposes of CHOICES:

Assistive devices, adaptive aids, controls or appliances that enable an Enrollee to increase his ability to perform ADLs or to perceive or control his environment. Examples include, but are not limited to, "grabbers" to pick objects off the floor, a strobe light to signify the smoke alarm has been activated, etc.

(b) For purposes of ECF CHOICES and for purposes of the Katie Beckett Program and limited to children enrolled in Katie Beckett Group Part A or Medicaid Diversion Group Part B:

An item, piece of equipment or product system, whether acquired commercially, modified or customized, that is used to increase, maintain, or improve functional capabilities and to support the individual's increased independence in the home, community living and participation, and individualized integrated employment or self-employment. The service covers purchases, leasing, shipping costs, and as necessary, repair of equipment required by the person to increase, maintain or improve his/her functional capacity to perform daily tasks in the community and in employment that would not be possible otherwise. All items must meet applicable standards of manufacture, design and installation. The person-centered support plan must include strategies for training the individual and any others who the individual will or may rely on in effectively using the assistive technology or adaptive equipment (e.g. his/her support staff; co-workers and supervisors in the place of employment; natural supports).

1. Assistive Technology Equipment and Supplies also covers the following:

(i) Evaluation and assessment of the assistive technology and adaptive equipment needs of the individual by an appropriate professional, including a functional evaluation of the impact of the provision of appropriate assistive technology and adaptive equipment through equipment trials and appropriate services to him/her in all environments with which the person interacts over the course of any 24 hour day, including the home, integrated employment setting(s) and community integration locations;

(ii) Services consisting of selecting, designing, fitting, customizing, adapting, applying, maintaining, updating, repairing, or replacing assistive technology devices and adaptive equipment;

(iii) Adaptive equipment to enable the individual to feed him/herself and/or complete oral hygiene as indicated while at home, work or in the community (e.g. utensils, gripping aid for utensils, adjustable universal utensil cuff, utensil holder, scooper trays, cups, bowls, plates, plate guards, non-skid pads for plates/bowls, wheelchair cup holders, adaptive cups that are specifically designed to allow a person to feed him/herself or for someone to safely assist a person to eat and drink, and adaptive toothbrushes);

(iv) Coordination and use of necessary therapies, interventions, or services with assistive technology devices, such as therapies, interventions, or services associated with other services in the person-centered support plan;

(v) Training, programming, demonstrations or technical assistance for the individual and for his/her providers of support (whether paid or unpaid) to facilitate the person's use of the assistive technology and adaptive equipment;

(vi) Adaptive switches and attachments;

(vii) Adaptive toileting equipment;

(viii) Communication devices and aids that enable the person to perceive, control or communicate with the environment, including a variety of devices for augmentative communication;

(ix) Assistive devices for persons with hearing and vision loss (e.g. assistive listening devices, TDD, large visual display services, Braille screen communicators, FM systems, volume control telephones, large print telephones and teletouch systems and long white canes with appropriate tips to identify footpath information for people with visual impairment;

(x) Computer equipment, adaptive peripherals and adaptive workstations to accommodate active participation in the workplace and in the community;

(xi) Software also is approved when required to operate accessories included for environmental control;

(xii) Pre-paid, pre-programmed cellular phones that allow an individual who is participating in employment or community integration activities without paid or natural supports and who may need assistance due to an accident, injury or inability to find the way home. The person's PCSP outlines a protocol that is followed if the individual has an urgent need to request help while in the community;

(xiii) Such other durable and non-durable medical equipment not available under the State Plan that is necessary to address functional limitations in the community, in the workplace, and in the home;

(xiv) Repair of equipment is covered for items purchased through this Waiver or purchased prior to Waiver participation, as long as the item is identified within this service definition and the cost of the repair does not exceed the cost of purchasing a replacement piece of equipment. The individual or legal guardian must own any piece of equipment that is repaired.

2. A written recommendation by an appropriate professional must be obtained to ensure that the equipment will meet the needs of the person. The recommendation of the Job Accommodation Networks (JAN) will meet this requirement for worksite technology. Depending upon the financial size of the employer or the public entity, those settings may be required to provide some of these items as part of their legal obligations under Title I or Title III of the ADA. Federal financial participation is not claimed for accommodations that are the legal responsibility of an employer or public entity, pursuant to Title I or Title III of the ADA.

3. Neither ECF CHOICES nor the Katie Beckett Program will cover Assistive Technology or Adaptive Equipment and services which are otherwise available to the individual under Section 110 of the Rehabilitation Act of 1973, or the IDEA (20 U.S.C. §§ 1401, et seq.). If this service is authorized, documentation is maintained that the service is not available to the individual under a program funded under Section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. §§ 1401, et seq.).

4. Assistive Technology, Adaptive Equipment and Supplies shall be limited to $5, 000 per person per calendar year.

(12) At Risk for Institutionalization.

(a) For purposes of CHOICES.

1. A requirement for eligibility to enroll in CHOICES Group 3 (including Interim CHOICES Group 3), whereby an individual does not meet the NF LOC criteria in place as of July 1, 2012, but meets the NF LOC criteria in place as of June 30, 2012, as defined in TennCare Rule 1200-13-01-.10(4) such that, in the absence of the provision of a moderate level of home and community based services and supports, the individual's condition and/or ability to continue living in the community will likely deteriorate, resulting in the need for more expensive institutional placement.

2. As it relates to CHOICES Group 3, includes only SSI eligible adults age sixty-five (65) or older or age twenty-one (21) or older with physical disabilities. As it relates to Interim CHOICES Group 3, open for enrollment only between July 1, 2012 and June 30, 2015, includes only adults age sixty-five (65) or older or age twenty-one (21) or older with physical disabilities who receive SSI or meet Nursing Facility Financial eligibility criteria.

(b) For purposes of ECF CHOICES:

The minimum medical eligibility (i.e., level of care) requirement to enroll in ECF CHOICES Group 4 or 5, whereby an Applicant does not meet NF LOC criteria, but has an intellectual or developmental disability as defined under T.C.A. § 33-1-101, as amended, including for an Applicant with ID, limitations in two (2) or more adaptive skill areas (i.e., communication, self-care, home living, social skills, community use, self-direction, health and safety, functional academics, leisure, and work); and for an Applicant age five (5) or older with DD, substantial functional limitations in three (3) or more major life activities (i.e., self-care; receptive and expressive language; learning; mobility; self-direction; capacity for independent living; and economic self-sufficiency); such that, in the absence of the provision of a moderate level of ECF CHOICES home and community based services and supports, the individual's condition and/or ability to continue living in the community will likely deteriorate, resulting in the need for more expensive institutional placement.

(c) For purposes of the Katie Beckett Program, Medicaid Diversion Group Part B only.

The minimum medical eligibility (level of care) requirement to enroll in Kate Beckett, Medicaid Diversion Group Part B, whereby a child does not meet the institutional level of care criteria specified in 1200-13-01-.11(3)(a) but does meet the criteria specified in 1200-13-01-.11(3)(b) and in the absence of the provision of a moderate level of home and community based services and supports, the child's condition and/or ability to continue living in the community will likely deteriorate, resulting in the child qualifying for more expensive institutional placement and for Medicaid.

(13) Attendant Care. For purposes of CHOICES, services to a Member who, due to age and/or Physical Disabilities, needs more extensive assistance than can be provided through intermittent Personal Care Visits (i.e., more than four (4) hours per occurrence or visits at intervals of less than four (4) hours between visits) to provide hands-on assistance and related tasks as specified below, and that may also include safety monitoring and/or supervision.

(a) Attendant Care may include assistance with the following:

1. ADLs such as bathing, dressing and personal hygiene, eating, toileting, transfers and ambulation.

2. Continuous safety monitoring and supervision during the period of service delivery.

(b) For Members who require hands-on assistance with ADLs, Attendant Care may also include the following homemaker services that are essential, although secondary, to the hands-on assistance with ADLs needed by the Member in order to continue living at home because there is no household member, relative, caregiver, or volunteer to meet the specified need, such as:

1. Picking up the Member's medications or shopping for the Member's groceries.

2. Preparing the Member's meals and/or educating caregivers about preparation of nutritious meals for the Member.

3. Household tasks such as sweeping, mopping, and dusting in areas of the home used by the Member, changing the Member's linens, making the Member's bed, washing the Member's dishes, and doing the Member's personal laundry, ironing and mending.

(c) Attendant Care shall not be provided for Members who do not require hands-on assistance with ADLs.

(d) Attendant Care shall be primarily provided in the Member's place of residence, except as permitted by rule and within the scope of service (e.g., picking up medications or shopping for groceries) when accompanying or transporting the Member into the community pursuant to Rule 1200-13-01-.05(8)(n), or under exceptional circumstances as authorized by an MCO in the POC to accommodate the needs of the Member.

(e) A single Contract Provider staff person or Consumer-Directed Worker may provide Attendant Care services to multiple CHOICES Members in the same home and during the same hours, as long as he can provide the services safely and appropriately to each Member. Such arrangements shall be documented in each Member's POC. In such instances, the total units of service provided by the staff person shall be allocated among the CHOICES Members, based on the percentage of total service units required by each Member on average. The Provider shall bill the MCO only once for each of the service units provided, and shall not bill an MCO or multiple MCOs separately to provide services to multiple Members at the same time.

(f) Regardless of payer, Attendant Care shall not be provided to Members living in an ACLF, Adult Care Home, Residential Home for the Aged or other group residential setting, or receiving CBRA (including Companion Care) or Short-Term NF services, or while a Member is receiving Adult Day Care services.

(g) Attendant Care shall not include:

1. Care or assistance including meal preparation or household tasks for other residents of the same household;

2. Yard work; or

3. Care of non-service related pets and animals.

(14) Automated Health Care and Related Expenses Reimbursement. For purposes of the Katie Beckett Program only and limited to children enrolled in Medicaid Diversion Group Part B:

(a) Payment or reimbursement, using the vendor contracted by DIDD, of the child's qualified medical and related expenses as follows:

1. Private insurance deductibles and co-payments for physician and nursing services, therapies, and prescription drugs;

2. Medical equipment and supplies;

3. Dental, vision, and hearing services;

4. Medical mileage; and

5. Other medical expenses as determined by the Internal Revenue Service to be eligible as an itemized medical and dental expenses deduction on Schedule A (Form 1040 or 1040-SR) or qualified for payment or reimbursement under a Healthcare Reimbursement Account, Health Savings Account or Flexible Spending Account, except that health insurance premiums shall be covered only as part of the Health Insurance Premium Assistance benefit).

(b) The child's parent or legal guardian shall specify the annual amount to be available for payment or reimbursement through the Automated Health Care and Related Expenses Reimbursement benefit each year, in accordance with processes established by DIDD, subject to the $10, 000 per child per year limit on total benefits available through Medicaid Diversion Group Part B and approval of the ISP by DIDD. Once established, this amount shall not be changed for the year. Payments or reimbursement for Automated Health Care and Related Expenses Reimbursement shall be limited to the amount specified in the child's approved ISP.

(c) To be covered and eligible for reimbursement, the child's parent or legal guardian shall submit documentation to the vendor contracted by DIDD as requested, sufficient to confirm the expense's eligibility for payment or reimbursement. The child's parent or legal guardian shall comply with all applicable requirements of DIDD's contracted vendor in order to receive this benefit.

(d) A period of ninety (90) days shall be provided at the end of each year for submission of final expenditures incurred during the annual period.

(e) Any funds remaining in the child's Automated Health Care and Related Expenses Reimbursement benefit at the end of the year shall be forfeited to the Katie Beckett program and shall not be permitted to "roll over" to the next year.

(15) Back-up Plan. A written plan that is a required component of the plan of care for all CHOICES members receiving companion care or the plan of care or person-centered support plan, as appropriate, for CHOICES or ECF CHOICES members receiving non-residential CHOICES or ECF CHOICES HCBS, all Katie Beckett Group Part A and Medicaid Diversion Group Part B members receiving Katie Beckett HCBS, and all members (including, but not limited to CHOICES, ECF CHOICES, and Katie Beckett Group Part A members) receiving home health (HH) or private duty nursing (PDN) services in their own homes and which specifies family members, and other unpaid persons as well as paid consumer-directed workers and/or contract providers who are available, have agreed to serve as back-up, and who will be contacted to deliver needed care or support in situations when regularly scheduled CHOICES, ECF CHOICES, or Katie Beckett HCBS providers or workers, or home health or private duty nurses or aides are unavailable or do not arrive as scheduled. A CHOICES or ECF CHOICES member or his/her representative may not elect, as part of the back-up plan, to go without services, nor may a Katie Beckett Group Part A or Medicaid Diversion Group Part B member or person receiving HH and/or PDN go without needed services. Inpatient admission shall not be considered an adequate back-up plan. The back-up plan shall include the names and telephone numbers of persons and agencies to contact and the services to be provided by each of the listed contacts. The member and his/her representative or for children in Katie Beckett Group Part A or Medicaid Diversion Group Part B, the child's parent or legal guardian shall have primary responsibility for the development and implementation of the back-up plan for consumer directed services. The FEA will assist as needed with the development and verification of the initial back-up plan for consumer direction. The CHOICES care coordinator ECF support coordinator, Nurse Care Manager or DIDD case manager, shall be responsible for assistance as needed with implementing the back-up plan and for updating and verifying the back-up plan on an ongoing basis.

(16) Bed Hold. The policy by which ICFs/IID are reimbursed for holding a resident's bed while he is away from the facility, in accordance with this Chapter.

(17) Benefits Counseling. For purposes of ECF CHOICES only and limited to persons age 16 or older:

(a) A service designed to inform the individual (and guardian, conservator and/or family, if applicable) of the multiple pathways to ensuring individualized integrated employment or self-employment that results in increased economic self-sufficiency (net financial benefit) through the use of various work incentives. This service should also repudiate myths and alleviate fears and concerns related to seeking and working in individualized integrated employment or self-employment through an accurate, individualized assessment. The service provides information to the individual (and guardian, conservator and/or family, if applicable) regarding the full array of available work incentives for essential benefit programs including SSI, SSDI, Medicaid, Medicare, ECF, housing subsidies, food stamps, etc.

(b) The service also will provide information and education to the person (and guardian, conservator and/or family, if applicable) regarding income reporting requirements for public benefit programs, including the Social Security Administration.

(c) Benefits counseling provides work incentives counseling and planning services to persons actively considering or seeking individualized integrated employment or self-employment, or career advancement in either of these types of employment.

(d) This service is provided by a certified Community Work Incentives Coordinator (CWIC). In addition to ensuring this service is not otherwise available to the individual under Section 110 of the Rehabilitation Act of 1973, or the IDEA (20 U.S.C. §§ 1401, et seq.), ECF CHOICES may not fund this service if CWIC Benefits Counseling services funded through the Federal Work Incentives Planning and Assistance (WIPA) program are available to the individual.

(e) Service must be provided in a manner that supports the person's communication style and needs, including, but not limited to, age appropriate communications, translation/interpretation services for persons of limited English-proficiency or who have other communication needs requiring translation including sign language interpretation, and ability to communicate with a person who uses an assistive communication device.

(f) Benefits Counseling services are paid for on an hourly basis and limited in the following ways:

1. Initial Benefits Counseling for someone actively considering or seeking individualized integrated employment or self-employment, or career advancement in these types of employment: up to twenty (20) hours. This service may be authorized no more than once every two (2) years (with a minimum of two 365-day intervals between services).

2. Supplementary Benefits Counseling for someone evaluating an individualized integrated job offer/promotion or self-employment opportunity: up to an additional six (6) hours. This service may be authorized up to three (3) times per year if needed.

3. PRN Problem-Solving services for someone to maintain individualized integrated employment or self-employment: up to eight (8) hours per situation requiring PRN assistance. This service may be authorized up to four (4) times per year if necessary for the individual to maintain individualized integrated employment or self-employment.

(18) Care Coordinator. For purposes of CHOICES, a person who is employed or contracted by an MCO to perform the continuous process of care coordination:

(a) Assessing a Member's physical, behavioral, functional, and psychosocial needs;

(b) Identifying the physical health, behavioral health, and LTSS and other social support services and assistance (e.g., housing or income assistance) necessary to meet identified needs;

(c) Ensuring timely access to and provision, coordination and monitoring of physical health, behavioral health, and LTSS needed to help the Member maintain or improve his physical or behavioral health status or functional abilities and maximize independence; and

(d) Facilitating access to other social support services and assistance needed in order to ensure the Member's health, safety and welfare, and as applicable, to delay or prevent the need for more expensive institutional placement.

(19) Career Advancement. For purposes of ECF CHOICES only and limited to persons age 16 or older:

(a) This is a time-limited career planning and advancement support service for persons currently engaged in individualized integrated employment or self-employment who wish to obtain a promotion and/or a second individualized integrated employment or self-employment opportunity. The service is time-limited and focuses on developing and successfully implementing a plan for achieving increased income and economic self-sufficiency through promotion to a higher paying position or through a second individualized integrated employment or self-employment opportunity.

(b) The outcomes of this service are:

1. The identification of the person's specific career advancement objective;

2. Development of a viable plan to achieve this objective; and

3. Implementation of the plan which results in the person successfully achieving his/her specific career advancement objective.

(c) Career Advancement is paid on an outcome basis, after key milestones are accomplished:

1. Outcome payment number one is paid after the written plan to achieve the person's specific career advancement objective is reviewed and approved. Note: The written plan must follow the template prescribed by TennCare.

2. Outcome payment number two is paid after the person has achieved his/her specific career advancement objective and has been in the new position or second job for a minimum of two (2) weeks.

(d) This service may not be included on a Person-Centered Support Plan if the PCSP also includes any of the following services: Integrated Employment Path Services, Exploration, Discovery, Situational Observation and Assessment, Job Development or Self-Employment Plan, or Job Development or Self-Employment Start-Up. This service may not be authorized retroactive to a promotion or second job being made available to a person. Supports for Career Advancement may be authorized and paid once every three (3) years (with a minimum of three 365-day intervals between services), if evidence exists that the individual is eligible for promotion or able to present as a strong candidate for employment in a second job (e.g. has strong reference, performance reviews and attendance record from current employer). The only exception is in situations where the provider previously authorized and paid for outcome payment number one but did not also earn outcome payment number two (because they did not successfully obtain a promotion or second job for the person). In this situation, reauthorization for outcome payments number one and two may occur a maximum of once per year (with a minimum 365-day interval between services), so long as the reauthorization involves the use of a new/different provider.

(20) Caregiver. For purposes of CHOICES, ECF CHOICES, or Katie Beckett Group Part A, a person who:

(a) Is a family member or is unrelated to the member but has a close, personal relationship with the member; and

(b) Is routinely involved in providing unpaid support and assistance to the member.

(c) A person who satisfies the criteria for caregiver in (a) and (b) above may also be designated by the member as a representative for CHOICES or ECF CHOICES or for consumer direction of eligible CHOICES or ECF CHOICES HCBS.

(d) For purposes of Katie Beckett Group Part A, the caregiver is generally the child's parent or legal guardian except when someone other than the child's parent or legal guardian is routinely involved in providing unpaid support and assistance to the child.

(21) Centers for Medicare and Medicaid Services (CMS). The agency within the United States Department of Health and Human Services that is responsible for administering Titles XVIII, XIX, and XXI of the Social Security Act.

(22) Certification.

(a) A process by which a Physician who is licensed as a doctor of medicine or doctor of osteopathy signs and dates a PAE signifying the following:

1. The person requires the requested level of institutional care or reimbursement (Level 1 NF, Level 2 NF, Enhanced Respiratory Care, or ICF/IID) or, in the case of a Section 1915(c) HCBS Waiver program or PACE, requires HCBS as an alternative to the applicable level of institutional care for which the individual would qualify; and

2. The requested LTSS are medically necessary for the individual.

(b) Consistent with requirements pertaining to certification of the need for SNF care set forth at 42 CFR § 424.20 and in Section 3108 of the Affordable Care Act, certification of the need for NF care may be performed by a nurse practitioner, clinical nurse specialist, or physician assistant, none of whom has a direct or indirect employment relationship with the facility but who is working in collaboration with a Physician.

(c) Physician certification is not required for CHOICES HCBS.

(d) For purposes of Katie Beckett Group Part A and the Continued Eligibility Group Part C,

1. The child's treating physician must certify that the PAE accurately reflects the child's physical, behavioral, and functional needs and that home-based services including HCBS, are medically necessary and that the child's needs can be safely met at home,

2. Physician certification shall not be required for enrollment in Medicaid Diversion Group Part B.

(23) CHOICES. See "TennCare CHOICES in Long-Term Services and Supports."

(24) CHOICES 1 and 2 Carryover Group.

(a) Individuals who were enrolled in CHOICES Group 1 or CHOICES Group 2 as of June 30, 2012, but who, upon redetermination, no longer qualify for enrollment due solely to the State's modification of its NF LOC criteria.

(b) Subject to the requirements set forth in 1200-13-01-.05(3)(b) 6., Members eligible for TennCare in the CHOICES 1 and 2 Carryover Group may continue to qualify in this group after June 30, 2012, so long as they continue to meet NF financial eligibility, continue to meet the NF LOC criteria in place as of June 30, 2012, and remain continuously enrolled in the CHOICES 1 and 2 Carryover Group and in CHOICES Group 1 or CHOICES Group 2.

(25) CHOICES 217-Like Group. Individuals age sixty-five (65) and older and adults age twenty-one (21) and older with Physical Disabilities who meet the NF LOC criteria, who could have been eligible for HCBS under 42 C.F.R. § 435.217 had the State continued its Section 1915(c) Statewide E/D Waiver and who need and are receiving CHOICES HCBS as an alternative to NF care. This group is subject to the Enrollment Target for CHOICES Group 2.

(26) CHOICES At-Risk Demonstration Group.

(a) Individuals age sixty-five (65) and older and adults age twenty-one (21) and older with Physical Disabilities who meet NF financial eligibility requirements for TennCare-reimbursed LTSS, meet the NF LOC in place on June 30, 2012, but not the NF LOC in place on July 1, 2012, and who, in the absence of CHOICES HCBS available through CHOICES Group 3, are At Risk for Institutionalization as defined in these rules.

(b) Members eligible for TennCare in the CHOICES At-Risk Demonstration Group on June 30, 2015, may continue to qualify in this group after June 30, 2015, so long as they continue to meet NF financial eligibility, continue to be At Risk for Institutionalization as defined in these rules, and remain continuously enrolled in the CHOICES At-Risk Demonstration Group and in CHOICES Group 3.

(27) CHOICES Group 1. Individuals of all ages who are receiving TennCare-reimbursed care in a NF.

(28) CHOICES Group 2. Individuals age sixty-five (65) and older and adults age twenty-one (21) and older with Physical Disabilities who meet the NF LOC criteria and who qualify for TennCare either as SSI recipients or in an institutional category (i.e., as Members of the CHOICES 217-Like demonstration population), and who need and are receiving CHOICES HCBS as an alternative to NF care. The Bureau has the discretion to apply an Enrollment Target to this group, as described in this Chapter.

(29) CHOICES Group 3. Individuals age sixty-five (65) and older and adults age twenty-one (21) and older with Physical Disabilities who qualify for TennCare as SSI recipients, who do not meet the NF LOC, but who, in the absence of CHOICES HCBS, are At Risk for Institutionalization, as defined by the State. The Bureau has the discretion to apply an Enrollment Target to this group, as described in this Chapter.

(30) CHOICES Home and Community-Based Services (HCBS). Services that are available only to eligible persons enrolled in CHOICES Group 2 or Group 3 as an alternative to long-term care institutional services in a nursing facility or to delay or prevent placement in a nursing facility. Only certain CHOICES HCBS are eligible for Consumer Direction. CHOICES HCBS do not include home health or private duty nursing services or any other HCBS that are covered by Tennessee's Title XIX State Plan or under the TennCare demonstration for all eligible enrollees, although such services are subject to estate recovery and shall be counted for purposes of determining whether a CHOICES Group 2 member's needs can be safely met in the community within his or her individual cost neutrality cap.

(31) CHOICES Member. An individual who has been enrolled by the Bureau into CHOICES.

(32) Chronic Ventilator Care Reimbursement. The rate of reimbursement provided for NF services, including enhanced respiratory care assistance, delivered by a NF that meets the requirements in Rule 1200-13-01-.03(5) to residents determined by the Bureau to meet the medical eligibility criteria in Rule 1200-13-01-.10(5)(d).

(33) Community-Based Residential Alternatives (CBRA) to institutional care. For purposes of CHOICES and ECF CHOICES:

(a) Residential services that offer a cost-effective, community-based alternative to NF care for individuals who are elderly and/or adults with Physical Disabilities and for individuals with I/DD.

(b) CBRAs include, but are not limited to:

1. Services provided in a licensed facility such as an ACLF or Critical Adult Care Home, and residential services provided in a licensed home or in the person's home by an appropriately licensed provider such as Community Living Supports and Community Living Supports-Family Model; and

2. Companion Care.

(34) Community Integration Support Services.

(a) For purposes of ECF CHOICES:

1. Services which coordinate and provide supports for valued and active participation in integrated daytime and nighttime activities that build on the person's interests, preferences, gifts, and strengths while reflecting the person's goals with regard to community involvement and membership. This service involves participation in one or more integrated community settings, in activities that involve persons without disabilities who are not paid or unpaid caregivers. Community Integration Support Services are designed to promote maximum participation in integrated community life while facilitating meaningful relationships, friendships and social networks with persons without disabilities who share similar interests and goals for community involvement and participation.

2. Community Integration Support Services shall support and enhance, rather than supplant, an individual's involvement in public education, post-secondary education/training and individualized integrated employment or self-employment (or services designed to lead to these types of employment).

3. Community Integration Support Services enable the person to increase or maintain his/her capacity for independent participation in community life and to develop age-appropriate social roles valued by the community by learning, practicing and applying skills necessary for full inclusion in the person's community, including skills in arranging and using public transportation for individuals aged 16 or older.

4. Community Integration Support Services provide assistance for active and positive participation in a broad range of integrated community settings that allow the person to engage with people who do not have disabilities who are not paid or unpaid caregivers. The service is expected to result in the person developing and sustaining a range of valued, age-appropriate social roles and relationships; building natural supports; increasing independence; and experiencing meaningful community integration and inclusion. Activities are expected to increase the individual's opportunity to build connections within his/her local community and include (but are not limited to) the following:

(i) Supports to participate in age-appropriate community activities, groups, associations or clubs to develop social networks with community organizations and clubs;

(ii) Supports to participate in community opportunities related to the development of hobbies or leisure/cultural interests or to promote personal health and wellness (e.g. yoga class, walking group, etc.);

(iii) Supports to participate in adult education and postsecondary education classes;

(iv) Supports to participate in formal/informal associations or community/neighborhood groups;

(v) Supports to participate in volunteer opportunities;

(vi) Supports to participate in opportunities focused on training and education for self-determination and self-advocacy;

(vii) Supports for learning to navigate the local community, including learning to use public transportation and/or private transportation available in the local area; and

(viii) Supports to maintain relationships with members of the broader community (e.g., neighbors, co-workers and other community members who do not have disabilities and who are not paid or unpaid caregivers) through natural opportunities and invitations that may occur.

5. This service includes a combination of training and supports as needed by the individual. The Community Integration Support Services provider shall be responsible for any personal assistance needs during the hours that Community Integration Support Services are provided; however, the personal assistance services may not comprise the entirety of the Community Integration Support Service. All providers of personal care under Community Integration Support Services meet the Personal Assistance provider qualifications.

6. This service shall be provided in a variety of integrated community settings that offer opportunities for the person to achieve his or her personally identified goals for community integration, involvement, exploration and for developing and sustaining a network of positive natural supports. All settings where Community Integration Support Services are provided must be non-disability specific and meet all federal standards for HCBS settings. This service is provided separate and apart from the person's place of residence. This service does not take place in licensed facilities, sheltered workshops or any type of facility owned, leased or operated by a provider of this service.

7. This service is available only:

(i) For children not yet old enough to work and/or not yet eligible for employment services who are enrolled in Essential Family Supports; or

(ii) As "wrap-around" supports to employment or employment services (Supported Employment Individual or Small Group services and/or Integrated Employment Path Services) for individuals not receiving Community Living Supports or Community Living Supports-Family Model; or

(iii) For individuals who are of legal working age (16+) not receiving Community Living Supports or Community Living Supports-Family Model who, after an Employment Informed Choice Process as defined by TennCare, have decided not to pursue employment; or

(iv) For individuals of retirement age not receiving Community Living Supports or Community Living Supports-Family Model who have made a choice not to pursue further employment opportunities.

8. For individuals receiving Community Integration Support Services who are of legal working age (16+), and not participating in employment or employment services, the option to pursue employment should be discussed at least semi-annually, unless the person is age 65 or older and has declined further interest in employment.

9. For individuals receiving Community Living Supports or Community Living Supports-Family Model, all services necessary to support community integration and participation are part of the scope of benefits provided under the CLS or CLS-FM benefit and shall not be authorized, provided or reimbursed as a separate service.

10. For individuals of appropriate age (18+), fading of the service and less dependence on paid support for ongoing participation in community activities and relationships is expected. Fading strategies, similar to those used in Supported Employment Job Coaching, should be utilized. Milestones for the reduction/fading of paid supports and the enhancement of natural supports must be established and monitored for this service.

11. Payment for registration, materials and supplies for participation in classes, conferences and similar types of activities, or club/association dues can be covered, but cannot exceed $500 per year for children under age 21 or $1, 000 per year for adults age 21 or older. These costs are not included in the rates paid to the providers of Community Integration Support Services and must be prior approved before being incurred.

12. Transportation to and from the service is not included in the rate paid for the service; but transportation during the service (when no-cost forms of transportation are not available or not being accessed) is included in the rate paid for the service.

13. Community Integration Support Services shall be limited as follows:

(i) For persons not working in Individualized Integrated Employment, Individualized Integrated Self-Employment, or Small Group Employment in the community or receiving at least one employment service, no more than 20 hours per week of Community Integration Support Services and Independent Living Skills Training combined after completing an Employment Informed Choice process.

(ii) For persons who are working in Individualized Integrated Employment, Individualized Integrated Self-Employment, or Small Group Employment in the community (not a sheltered workshop) or receiving at least one employment service, no more than 30 hours per week of Community Integration Support Services, Independent Living Skills Training, and Individual or Small Group Employment Supports combined.

(iii) For persons who are working in Individualized Integrated Employment or Individualized Integrated Self-Employment (not in a small group or in a sheltered workshop), no more than 40 hours per week of Community Integration Support Services, Independent Living Skills Training, Job Coaching, Co-Worker Supports, and the hours worked without paid supports combined.

(iv) For persons who are working in Individualized Integrated Employment or Individualized Integrated Self-Employment (not in a small group or in a sheltered workshop) at least 30 hours per week, no more than 50 hours per week of Community Integration Support Services, Independent Living Skills Training, Job Coaching, Co-Worker Supports, and the hours worked without paid supports combined.

(b) For purposes of the Katie Beckett Program and applicable only to children enrolled in Katie Beckett Group Part A or Medicaid Diversion Group Part B:

1. Services which coordinate and provide supports for valued and active participation in integrated daytime and nighttime activities that build on the person's interests, preferences, gifts, and strengths while reflecting the person's goals with regard to community involvement and membership. This service involves participation in one or more integrated community settings, in activities that involve persons without disabilities who are not paid or unpaid caregivers. Community Integration Support Services are designed to promote maximum participation in integrated community life while facilitating meaningful relationships, friendships and social networks with persons without disabilities who share similar interests and goals for community involvement and participation.

2. Community Integration Support Services shall support and enhance, rather than supplant, an individual's involvement in public education, post-secondary education/training and individualized integrated employment or self-employment (or services designed to lead to these types of employment).

3. Community Integration Support Services enable the person to increase or maintain his/her capacity for independent participation in community life and to develop age-appropriate social roles valued by the community by learning, practicing and applying skills necessary for full inclusion in the person's community, including skills in arranging and using public transportation for individuals aged 16 or older.

4. Community Integration Support Services provide assistance for active and positive participation in a broad range of integrated community settings that allow the person to engage with people who do not have disabilities who are not paid or unpaid caregivers. The service is expected to result in the person developing and sustaining a range of valued, age-appropriate social roles and relationships; building natural supports; increasing independence; and experiencing meaningful community integration and inclusion. Activities are expected to increase the individual's opportunity to build connections within his/her local community and include (but are not limited to) the following:

(i) Supports to participate in age-appropriate community activities, groups, associations or clubs to develop social networks with community organizations and clubs;

(ii) Supports to participate in community opportunities related to the development of hobbies or leisure/cultural interests or to promote personal health and wellness (e.g. yoga class, walking group, etc.);

(iv) Supports to participate in formal/informal associations or community/neighborhood groups;

(v) Supports to participate in volunteer opportunities;

(vi) Supports to participate in opportunities focused on training and education for self-determination and self-advocacy;

(vii) Supports for learning to navigate the local community, including learning to use public transportation and/or private transportation available in the local area; and

(viii) Supports to maintain relationships with members of the broader community (e.g., neighbors, co-workers and other community members who do not have disabilities and who are not paid or unpaid caregivers) through natural opportunities and invitations that may occur.

5. This service includes a combination of training and supports as needed by the individual. The Community Integration Support Services provider shall be responsible for any personal assistance needs during the hours that Community Integration Support Services are provided; however, the personal assistance services may not comprise the entirety of the Community Integration Support Service. All providers of personal care under Community Integration Support Services meet the Personal Assistance provider qualifications.

6. This service shall be provided in a variety of integrated community settings that offer opportunities for the person to achieve his or her personally identified goals for community integration, involvement, exploration and for developing and sustaining a network of positive natural supports. All settings where Community Integration Support Services are provided must be non-disability specific and meet all federal standards for HCBS settings. This service is provided separate and apart from the person's place of residence. This service does not take place in licensed facilities, sheltered workshops or any type of facility owned, leased or operated by a provider of this service.

7. Payment for registration, materials and supplies for participation in classes, conferences and similar types of activities, or club/association dues can be covered, but cannot exceed $500 per year. These costs are not included in the rates paid to the providers of Community Integration Support Services and must be prior approved before being incurred.

8. Transportation to and from the service is not included in the rate paid for the service; but transportation during the service (when no-cost forms of transportation are not available or not being accessed) is included in the rate paid for the service.

(c) Community Integration Support Services shall support and enhance, rather than supplant, an individual's involvement in public education, post-secondary education/training and individualized integrated employment or self-employment (or services designed to lead to these types of employment).

(d) Community Integration Support Services enable the person to increase or maintain his/her capacity for independent participation in community life and to develop age-appropriate social roles valued by the community by learning, practicing and applying skills necessary for full inclusion in the person's community, including skills in arranging and using public transportation for individuals aged 16 or older.

(e) Community Integration Support Services provide assistance for active and positive participation in a broad range of integrated community settings that allow the person to engage with people who do not have disabilities who are not paid or unpaid caregivers. The service is expected to result in the person developing and sustaining a range of valued, age-appropriate social roles and relationships; building natural supports; increasing independence; and experiencing meaningful community integration and inclusion. Activities are expected to increase the individual's opportunity to build connections within his/her local community and include (but are not limited to) the following:

1. Supports to participate in age-appropriate community activities, groups, associations or clubs to develop social networks with community organizations and clubs;

2. Supports to participate in community opportunities related to the development of hobbies or leisure/cultural interests or to promote personal health and wellness (e.g. yoga class, walking group, etc.);

3. Supports to participate in adult education and postsecondary education classes;

4. Supports to participate in formal/informal associations or community/neighborhood groups;

5. Supports to participate in volunteer opportunities;

6. Supports to participate in opportunities focused on training and education for self-determination and self-advocacy;

7. Supports for learning to navigate the local community, including learning to use public transportation and/or private transportation available in the local area; and

8. Supports to maintain relationships with members of the broader community (e.g., neighbors, co-workers and other community members who do not have disabilities and who are not paid or unpaid caregivers) through natural opportunities and invitations that may occur.

(f) This service includes a combination of training and supports as needed by the individual. The Community Integration Support Services provider shall be responsible for any personal assistance needs during the hours that Community Integration Support Services are provided; however, the personal assistance services may not comprise the entirety of the Community Integration Support Service. All providers of personal care under Community Integration Support Services meet the Personal Assistance provider qualifications.

(g) This service shall be provided in a variety of integrated community settings that offer opportunities for the person to achieve his or her personally identified goals for community integration, involvement, exploration and for developing and sustaining a network of positive natural supports. All settings where Community Integration Support Services are provided must be non-disability specific and meet all federal standards for HCBS settings. This service is provided separate and apart from the person's place of residence. This service does not take place in licensed facilities, sheltered workshops or any type of facility owned, leased or operated by a provider of this service.

(h) This service is available only:

1. For children not yet old enough to work and/or not yet eligible for employment services who are enrolled in Essential Family Supports; or

2. As "wrap-around" supports to employment or employment services (Supported Employment Individual or Small Group services and/or Integrated Employment Path Services) for individuals not receiving Community Living Supports or Community Living Supports-Family Model; or

3. For individuals who are of legal working age (16+) not receiving Community Living Supports or Community Living Supports-Family Model who, after an Employment Informed Choice Process as defined by TennCare, have decided not to pursue employment; or

4. For individuals of retirement age not receiving Community Living Supports or Community Living Supports-Family Model who have made a choice not to pursue further employment opportunities.

(i) For individuals receiving Community Integration Support Services who are of legal working age (16+), and not participating in employment or employment services, the option to pursue employment should be discussed at least semi-annually, unless the person is age 65 or older and has declined further interest in employment.

(j) For individuals receiving Community Living Supports or Community Living Supports-Family Model, all services necessary to support community integration and participation are part of the scope of benefits provided under the CLS or CLS-FM benefit and shall not be authorized, provided or reimbursed as a separate service.

(k) For individuals of appropriate age (18+), fading of the service and less dependence on paid support for ongoing participation in community activities and relationships is expected. Fading strategies, similar to those used in Supported Employment Job Coaching, should be utilized. Milestones for the reduction/fading of paid supports and the enhancement of natural supports must be established and monitored for this service.

(l) Payment for registration, materials and supplies for participation in classes, conferences and similar types of activities, or club/association dues can be covered, but cannot exceed $500 per year for children under age 21 or $1, 000 per year for adults age 21 or older. These costs are not included in the rates paid to the providers of Community Integration Support Services and must be prior approved before being incurred.

(m) Transportation to and from the service is not included in the rate paid for the service; but transportation during the service (when no-cost forms of transportation are not available or not being accessed) is included in the rate paid for the service.

(n) Community Integration Support Services shall be limited as follows:

1. For persons not working in Individualized Integrated Employment, Individualized Integrated Self-Employment, or Small Group Employment in the community or receiving at least one employment service, no more than 20 hours per week of Community Integration Support Services and Independent Living Skills Training combined after completing an Employment Informed Choice process.

2. For persons who are working in Individualized Integrated Employment, Individualized Integrated Self-Employment, or Small Group Employment in the community (not a sheltered workshop) or receiving at least one employment service, no more than 30 hours per week of Community Integration Support Services, Independent Living Skills Training, and Individual or Small Group Employment Supports combined.

3. For persons who are working in Individualized Integrated Employment or Individualized Integrated Self-Employment (not in a small group or in a sheltered workshop), no more than 40 hours per week of Community Integration Support Services, Independent Living Skills Training, Job Coaching, Co-Worker Supports, and the hours worked without paid supports combined.

4. For persons who are working in Individualized Integrated Employment or Individualized Integrated Self-Employment (not in a small group or in a sheltered workshop) at least 30 hours per week, no more than 50 hours per week of Community Integration Support Services, Independent Living Skills Training, Job Coaching, Co-Worker Supports, and the hours worked without paid supports combined.

(35) Community Living Supports (CLS). For the purposes of CHOICES and ECF CHOICES, this service is available only to CHOICES Group 2 and 3 Members and ECF CHOICES Group 5 and 6 Members as appropriate:

(a) A CBRA licensed by the DIDD in accordance with T.C.A. Title 33 and TDMHSAS Rules 0940-05-24, 0940-05-28 or 0940-05-32, as applicable, that encompasses a continuum of residential support options for up to four individuals living in a home that:

1. Supports each resident's independence and full integration into the community;

2. Ensures each resident's choice and rights; and

3. Comports fully with standards applicable to HCBS settings detailed in 42 C.F.R. § 441.301(c)(4) and (5), including those requirements applicable to provider-owned or controlled homes, as applicable, including any exception as supported by the individual's specific assessed need and set forth in the person-centered plan of care.

(b) CLS services are individualized based on the needs of each resident and specified in the person-centered plan of care. Services may include hands-on assistance, supervision, transportation, and other supports intended to help the individual exercise choices such as:

1. Selecting and moving into a home.

2. Locating and choosing suitable housemates.

3. Acquiring and maintaining household furnishings.

4. Acquiring, retaining, or improving skills needed for activities of daily living or assistance with activities of daily living as needed, such as bathing, dressing, personal hygiene and grooming, eating, toileting, transfer, and mobility.

5. Acquiring, retaining, or improving skills needed for instrumental activities of daily living or assistance with instrumental activities of daily living as needed, such as household chores, meal planning, shopping, preparation and storage of food, and managing personal finances.

6. Building and maintaining interpersonal relationships with family and friends.

7. Pursuing educational goals and employment opportunities.

8. Participating fully in community life, including faith-based, social, and leisure activities selected by the individual.

9. Scheduling and attending appropriate medical services.

10. Self-administering medications, including assistance with administration of medications as permitted pursuant to T.C.A. §§ 68-1-904 and 71-5-1414.

11. Managing acute or chronic health conditions, including nurse oversight and monitoring, and skilled nursing services as needed for routine, ongoing health care tasks, such as blood sugar monitoring and management, oral suctioning, tube feeding, bowel care, etc.

12. Becoming aware of, and effectively using, transportation, police, fire, and emergency help available in the community to the general public.

13. Asserting civil and statutory rights through self-advocacy.

(36) Community Living Supports Family Model (CLS-FM). For the purposes of CHOICES and ECF CHOICES, this service is available to CHOICES Group 2 and 3 Members and ECF CHOICES Group 5 and Group 6 Members as appropriate:

(a) A CBRA licensed by the DIDD in accordance with T.C.A. Title 33 and TDMHSAS Rule 0940-05-26 that encompasses a continuum of residential support options for up to three individuals living in the home of trained family caregivers (other than the individual's own family) in an "adult foster care" arrangement. In this type of shared living arrangement, the provider allows the individual(s) to move into his or her existing home in order to integrate the individual into the shared experiences of a home and a family and provide the individualized services that:

1. Support each resident's independence and full integration into the community;

2. Ensure each resident's choice and rights; and

3. Support each resident in a manner that comports fully with standards applicable to HCBS settings detailed in 42 C.F.R. § 441.301(c)(4)-(5), including those requirements applicable to provider-owned or controlled homes, as applicable, including any exception as supported by the individual's specific assessed need and set forth in the person-centered plan of care.

(b) CLS-FM services are individualized based on the needs of each resident and specified in the person-centered plan of care. Services may include hands-on assistance, supervision, transportation, and other supports intended to help the individual exercise choices such as:

1. Selecting and moving into a home.

2. Locating and choosing suitable housemates.

3. Acquiring and maintaining household furnishings.

4. Acquiring, retaining, or improving skills needed for activities of daily living or assistance with activities of daily living as needed, such as bathing, dressing, personal hygiene and grooming, eating, toileting, transfer, and mobility.

5. Acquiring, retaining, or improving skills needed for instrumental activities of daily living or assistance with instrumental activities of daily living as needed, such as household chores, meal planning, shopping, preparation and storage of food, and managing personal finances.

6. Building and maintaining interpersonal relationships with family and friends.

7. Pursuing educational goals and employment opportunities.

8. Participating fully in community life, including faith-based, social, and leisure activities selected by the individual.

9. Scheduling and attending appropriate medical services.

10. Self-administering medications, including assistance with administration of medications as permitted pursuant to T.C.A. §§ 68-1-904 and 71-5-1414.

11. Managing acute or chronic health conditions, including nurse oversight and monitoring, and skilled nursing services as needed for routine, ongoing health care tasks, such as blood sugar monitoring and management, oral suctioning, tube feeding, bowel care, etc.

12. Becoming aware of, and effectively using, transportation, police, fire, and emergency help available in the community to the general public.

13. Asserting civil and statutory rights through self-advocacy.

(37) Community Personal Needs Allowance. See "Personal Needs Allowance (PNA)."

(38) Community Support Development, Organization and Navigation. For purposes of ECF CHOICES and limited to members enrolled in ECF CHOICES Group 4 (Essential Family Supports), and for purposes of the Katie Beckett Program and limited to children enrolled in Katie Beckett Group Part A or Medicaid Diversion Group Part B:

(a) Assists individuals and families in:

1. Promoting a spirit of personal reliance and contribution, mutual support and community connection;

2. Developing social networks and connections within local communities; and

3. Emphasizing, promoting and coordinating the use of unpaid supports to address individual and family needs in addition to paid services.

(b) Supports provided include:

1. Helping individuals and family caregivers to develop a network for information and mutual support from others who receive services or family caregivers of individuals with disabilities;

2. Assisting individuals with disabilities and family caregivers with identifying and utilizing supports available from community service organizations, such as churches, schools, colleges, libraries, neighborhood associations, clubs, recreational entities, businesses and community organizations focused on exchange of services (e.g. time banks); and

3. Assisting individuals with disabilities and family caregivers with providing mutual support to one another (through service/support exchange), and contributions offered to others in the community.

(c) These services are provided by a Community Navigator and reimbursed on a per person (or family) per month basis, based on specific goals and objectives as specified in the person-centered support plan.

(39) Community Transportation. For purposes of ECF CHOICES and for purposes of the Katie Beckett Program and limited to children enrolled in Katie Beckett Group Part A Group or Medicaid Diversion Group Part B:

(a) Community Transportation services are non-medical transportation services offered in order to enable individuals, and their personal assistants as needed, to gain access to employment, community life, activities and resources that are identified in the person-centered support plan. These services allow individuals to get to and from typical day-to-day, non-medical activities such as individualized integrated employment or self-employment (if not home-based), the grocery store or bank, social events, clubs and associations and other civic activities, or attending a worship service. This service is made available when public or other no-cost community-based transportation services are not available and the person does not have access to transportation through any other means (including natural supports).

(b) Whenever possible, family, neighbors, co-workers, carpools or friends are utilized to provide transportation assistance without charge. When this service is authorized, the most cost-effective option should be considered first. This service is in addition to the medical transportation service offered under the Medicaid State Plan, which includes transportation to medical appointments as well as emergency medical transportation.

(c) Community Transportation shall be limited to no more than $225 per month for persons electing to receive this service through Consumer Direction.

(40) Companion Care. For purposes of CHOICES:

(a) A consumer-directed residential model in which a CHOICES Member may choose to select, employ, supervise and pay, using the services of an FEA, a live-in companion who will be present in the Member's home and provide frequent intermittent assistance or continuous supervision and monitoring throughout the entire period of service duration.

(b) Such model shall be available only for a CHOICES Member who requires and does not have available through family or other caregiving supports frequent intermittent assistance with ADLs or supervision and monitoring for extended periods of time that cannot be accomplished more cost-effectively with other non-residential services.

(c) A CHOICES Member who requires assistance in order to direct his Companion Care may designate a Representative to assume CD of Companion Care services on his behalf, pursuant to requirements for Representatives otherwise applicable to CD.

(d) Regardless of payer, Companion Care shall not be provided to Members living in an ACLF, Adult Care Home, Residential Home for the Aged or other group residential setting, or receiving Short-Term NF services or Adult Day Care services.

(e) Companion Care is only available through CD.

(41) Comparable Cost of Institutional Care. For purposes of Katie Beckett Group Part A and the Continued Eligibility Group Part C, the requirement that in order to qualify for enrollment in Katie Beckett Group Part A or in the Continued Eligibility Group Part C, the estimated amount that would be expended by the Medicaid program for the child's care outside an institution cannot be greater than the estimated amount that would otherwise be expended by the Medicaid program for the child's care within an appropriate institution, as further defined in Rule .32(4)(d).

(42) Competent Adult. For purposes of Self-Direction of Health Care Tasks in CD, a person age twenty-one (21) or older who has the capability and capacity to evaluate knowledgeably the options available and the risks attendant upon each and to make an informed decision acting in accordance with his own preferences and values. A person is presumed competent unless a decision to the contrary is made.

(43) Consumer. Except when used regarding consumer direction of eligible CHOICES or ECF CHOICES HCBS, an individual who uses a mental health or substance abuse service.

(44) Consumer-Directed Worker (Worker). An individual who has been hired by a CHOICES or ECF CHOICES member participating in consumer direction of eligible CHOICES or ECF CHOICES HCBS or his/her representative or by a parent or legal guardian of a Katie Beckett Group Part A member participating in consumer direction of eligible Katie Beckett HCBS to provide one or more eligible CHOICES, ECF CHOICES, or Katie Beckett HCBS to the member. Worker does not include an employee of an agency that is being paid by an MCO to provide HCBS to the member.

(45) Consumer Direction of Eligible CHOICES or ECF CHOICES HCBS. The opportunity for a CHOICES or ECF CHOICES member assessed to need specified types of CHOICES or ECF CHOICES HCBS including for purposes of CHOICES, attendant care, personal care, in-home respite, companion care; and for purposes of ECF CHOICES, personal assistance, supportive home care, hourly respite, and community transportation; and/or any other service specified in TennCare rules as available for consumer direction to elect to direct and manage (or to have a representative direct and manage) certain aspects of the provision of such services-primarily, the hiring, firing, and day-to-day supervision of consumer-directed workers delivering the needed service(s) and for ECF CHOICES, the delivery of each eligible ECF CHOICES HCBS within the authorized budget for that service.

(46) Consumer Direction of Eligible Katie Beckett HCBS. The opportunity for the parent or legal guardian of a child enrolled in Katie Beckett Group Part A or Medicaid Diversion Group Part B assessed to need specified types of Katie Becket HCBS set forth in TennCare rules as available for consumer direction to elect to direct and manage (or in limited circumstances to have a representative direct and manage) certain aspects of the provision of services - primarily, the hiring, firing, and day-to-day supervision of consumer directed workers delivering the needed service(s) and the delivery of each eligible Katie Beckett HCBS within the authorized budget for that service. Eligible Katie Beckett HCBS do not include home health or private duty nursing.

(47) Continued Eligibility Group Part C. A TennCare demonstration population category that provides continuity of Medicaid coverage, state plan benefits (including EPSDT), and providers for children who have been enrolled in Medicaid but are no longer eligible in any category, and who are described in Section 1902(e)(3) and meet all of the eligibility criteria for enrollment into Katie Beckett Group Part A, as determined by TennCare, but for whom there is not an available slot in Katie Beckett Group Part A. Children in the Continued Eligibility Group Part C are not eligible to receive Katie Beckett Group Part A wraparound HCBS.

(48) Contract Provider. A provider who is under contract with an Enrollee's MCO. Also called "Network Provider" or "In-Network Provider."

(49) Cost-Effective Alternative (CEA) Service.

(a) A service that is not a covered service but that is approved by TennCare and CMS and provided at an MCO's discretion. There is no entitlement to receive these services.

(b) CEA services may be provided because they are:

1. Alternatives to covered TennCare services that, in the MCO's judgment, are cost effective; or

2. Preventive in nature and offered to avoid the development of conditions that, in the MCO's judgment, would require more costly treatment in the future.

(c) CEA services need not be determined medically necessary except to the extent that they are provided as an alternative to covered TennCare services. Even if medically necessary, CEA services are not covered services and are provided only at an MCO's discretion.

(d) For purposes of CHOICES, CEA services may include the provision of CHOICES HCBS as an alternative to NF care when the Enrollment Target for CHOICES Group 2 has been reached as described in Rule 1200-13-01-.05.

(e) For purposes of ECF CHOICES, CEA services may include the provision of ECF CHOICES HCBS as an alternative to NF care when the Enrollment Target for the benefit group in which the Member will be enrolled has been reached as described in Rule 1200-13-01-.31.

(50) Cost Neutrality Cap. For purposes of CHOICES Group 2, the average cost of the level of NF reimbursement that would be paid if the Member were institutionalized. The Cost Neutrality Cap functions as a limit on the total cost of HCBS that can be provided to the individual in the home or community setting, including CHOICES HCBS, HH Services and PDN Services. The Cost Neutrality Cap shall be individually applied.

(51) Co-Worker Supports. For purposes of ECF CHOICES only and limited to persons age 16 or older:

(a) This service involves a provider of Job Coaching for Individualized Integrated Employment entering into an agreement with an individual's employer to reimburse the employer for supports provided by one or more supervisors and/or co-workers, acceptable to the individual, to enable the person to maintain individualized integrated employment with the employer. This service cannot include payment for the supervisory and co-worker supports rendered as a normal part of the business setting and that would otherwise be provided to an employee without a disability. Additional natural supports for the individual, already negotiated with the employer, and provided through supervisors and co-workers, are not eligible for reimbursement under Co-Worker Supports. Only supports that must otherwise be provided by a Job Coach may be reimbursed under this service category. Co-Worker Supports would be authorized in situations where any of the following is true:

1. From the start of employment or at any point during employment, if the employer prefers (or the individual prefers and the employer agrees) to provide needed Job Coach supports, rather than having a Job Coach, either employed by a third party agency or self-employed, present in the business. Fading expectations should still be in place to maximize independence of the employed individual.

2. At any point in the individual's employment where needed Job Coaching supports can be most cost effectively provided by Co-Worker Supports and both the employer and individual agree to the use of Co-Worker Supports. Fading of Job Coaching supports may or may not still be occurring, but Co-Worker Supports should always be considered when ongoing fading of Job Coaching has stopped occurring.

3. For individuals who are expected to be able to transition to working only with employer supports available to any employee and additional negotiated natural supports if applicable. In this situation, Co-Worker Supports are authorized as a temporary (maximum twelve months) bridge to relying only on employer supports, and additional negotiated natural (unpaid) supports if applicable, to maintain employment. The supervisor(s) and/or co-worker(s) identified to provide the support to the individual must meet the qualifications for a legally responsible individual as provider of this service. The provider is responsible for ensuring these qualifications are met and also for oversight and monitoring of paid co-worker supports.

(b) The amount of time authorized for this service is negotiated with the employer and reflective of the specific needs the individual has for Co-Worker Supports above and beyond negotiated natural supports and supervisory/co-worker supports otherwise available to employees without disabilities. A 10% add-on to the 15 minute unit rate for the employer is applied to cover the service provider's role in administering Co-Worker Supports.

(c) Co-Worker Supports shall be limited as follows:

1. For persons who are working in Individualized Integrated Employment or Individualized Integrated Self-Employment (not in a small group or in a sheltered workshop), no more than 40 hours per week of Co-Worker Supports, Job Coaching, Community Integration Support Services, Independent Living Skills Training, and the hours worked without paid supports combined.

2. For persons who are working in Individualized Integrated Employment or Individualized Integrated Self-Employment (not in a small group or in a sheltered workshop) at least 30 hours per week, no more than 50 hours per week of Co-Worker Supports, Job Coaching, Community Integration Support Services, Independent Living Skills Training, and the hours worked without paid supports combined.

(52) Decision Making Supports. For purposes of ECF CHOICES and for purposes of the Katie Beckett Program and limited to children enrolled in Katie Beckett Group Part A or Medicaid Diversion Group Part B only:

(a) This service offers up to $500 in one-time consultation, education and assistance to family caregivers in understanding legal, financial, and other decision making supports and options for a person supported who cannot make some or all of their own decisions. These services shall be provided in a manner that seeks to provide support in the least-restrictive manner, preserving the rights and freedoms of the individual to the maximum extent possible and appropriate.

(b) This service begins with education and consultation from a qualified professional to help ensure understanding of the array of options available, including less restrictive options that can be used to preserve the person's rights and freedoms to the maximum extent possible and appropriate, while addressing decision making needs.

(c) Reimbursable services may then include:

(1) assistance with completing necessary paperwork and processes to establish an alternative to conservatorship, such as supported decision making, limited (and revocable) power of attorney, health care proxy, or trust; or limited or full or conservatorship that is specifically tailored to the individual's capacities and needs, if it is determined to be the least restrictive alternative;

(2) evaluating the appropriateness of a decision-making instrument currently in place and assistance with costs associated with terminating or revoking a conservatorship when less restrictive options would be appropriate; and

(3) training associated with decision-making support.

(d) Decision Making Supports shall be limited to $500 per lifetime.

(53) Dental Benefits Manager (DBM). See "Dental Benefits Manager" in Rule 1200-13-13-.01.

(54) Department of Intellectual and Developmental Disabilities (DIDD). The State entity contracted by TennCare to serve as the OAA for day-to-day operation of Section 1915(c) HCBS Waivers for persons with ID. DIDD is also responsible for the performance of contracted functions for ECF CHOICES and Katie Beckett Group Part A, and for administering Medicaid Diversion Group Part B, including redeterminations, as specified in an interagency agreement with TennCare.

(55) Designated Correspondent. A person or agency authorized by an individual on the PAE form to receive correspondence related to NF or ICF/IID services on his behalf.

(56) Developmental Disability(ies) (DD).

(a) Pursuant to T.C.A § 33-1-101, as amended, a developmental disability in a person over five (5) years of age means a condition that:

1. Is attributable to a mental or physical impairment or combination of mental and physical impairments;

2. Manifested before twenty-two (22) years of age; 3 Is likely to continue indefinitely;

4. Results in substantial functional limitations in three (3) or more of the following major life activities:

(i) Self-care;

(ii) Receptive and expressive language;

(iii) Learning;

(iv) Mobility;

(v) Self-direction;

(vi) Capacity for independent living; or

(vii) Economic self-sufficiency; and

5. Reflects the person's need for a combination and sequence of special interdisciplinary or generic services, supports, or other assistance that is likely to continue indefinitely and need to be individually planned and coordinated.

(b) Developmental disability in a person up to five (5) years of age means a condition of substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in developmental disability as defined for persons over five (5) years of age if services and supports are not provided.

(c) For purposes of ECF CHOICES, the determination that an Applicant has substantial functional limitations in three (3) or more major life activities shall be made by TennCare using an adaptive behavior (or life skills) assessment tool, and review of supporting medical evidence. Information gathered through such adaptive behavior (or life skills) assessment may be used by an Applicant for purposes of supporting functional deficits described in 1200-13-01-.10, or an Individual Acuity Score or an Applicant's total score on the NF LOC Acuity Scale, in accordance with criteria specified in Rule 1200-13-01-.10.

(57) Discovery. For purposes of ECF CHOICES only and limited to persons age 14 or older:

(a) This is a time-limited and targeted service for an individual who wishes to pursue individualized integrated employment or self-employment but for whom more information is needed to determine the following prior to pursuing individualized integrated employment or self-employment:

1. Strongest interests toward one or more specific aspects of the labor market;

2. Skills, strengths and other contributions likely to be valuable to employers or valuable to the community if offered through self-employment;

3. Conditions necessary for successful employment or self-employment.

(b) Discovery involves a comprehensive analysis of the person in relation to Parts 1., 2., and 3. above. Activities include observation of the person in familiar places and activities, interviews with family, friends and others who know the person well, observation of the person in an unfamiliar place and activity, and identification of the person's strong interests and existing strengths and skills that are transferable to individualized integrated employment or self-employment. Discovery also involves identification of conditions for success based on experience shared by the person and others who know the person well, and observation of the person during the Discovery process. The information developed through Discovery allows for activities of typical life to be translated into possibilities for individualized integrated employment or self-employment.

(c) Discovery results in the production of a detailed written Profile, using a standard template prescribed by TennCare, which summarizes the process, learning and recommendations to inform identification of the person's individualized integrated employment or self-employment goal(s) and strategies to be used in securing this employment or self-employment for the person.

(d) If Discovery is paid for through ECF CHOICES, the person should be assisted to apply to Vocational Rehabilitation (VR) for services to obtain individualized integrated employment or self-employment.

(e) The Discovery Profile should be shared with VR staff to facilitate the expeditious development of an Individual Plan for Employment (IPE).

(f) Discovery shall be limited to no more than ninety (90) calendar days from the date of service initiation. This service is expected, on average, to involve fifty (50) hours of service.

(g) The provider shall document each date of service, the activities performed that day, and the duration of each activity. The written Profile is due no later than fourteen (14) days after the last date of service is concluded. Discovery is paid on an outcome basis, after the written Profile is received and approved, and the provider submits documentation detailing each date of service, the activities performed that day, and the duration of each activity.

(h) After an individual has received the service for the first time, re-authorization may occur a maximum of once every three years (with a minimum of three 365-day intervals between services), and only if the person, at the time of re-authorization, is not already engaged in individualized integrated employment or self-employment, or other services to obtain such employment, and the person has a goal to obtain individualized integrated employment or self-employment within twelve (12) months.

(58) Disenrollment. The voluntary or involuntary termination of an individual's enrollment in an LTSS Program.

(59) Division of TennCare (TennCare). The division of the Department of Finance and Administration, the single state Medicaid agency that administers the TennCare Program. For the purposes of this Chapter, TennCare shall represent the State of Tennessee.

(60) Early and Periodic Screening, Diagnostic, and Treatment (EPSDT). A covered benefit for children enrolled in TennCare Medicaid. See Rule Chapter 1200-13-13 for additional information.

(61) ECF CHOICES 217-Like Group. Individuals with I/DD of all ages who meet the NF LOC criteria who need and are receiving HCBS, and who would be eligible in the same manner as specified under 42 C.F.R. § 435.217, 42 C.F.R. § 435.726, and Section 1902(a) of the Social Security Act, if the HCBS were provided under a Section 1915(c) Waiver. Enrollment in this group shall be subject to the enrollment targets established for each applicable ECF CHOICES benefit group. An Applicant may qualify in the ECF CHOICES 217-Like Group only when there is an available slot for enrollment into an ECF CHOICES benefit group for which the Applicant meets all eligibility and enrollment criteria, including prioritization criteria for enrollment into ECF CHOICES as established in these Rules, and when the Applicant upon approval of financial eligibility, will be enrolled by TennCare into such ECF CHOICES group.

(62) ECF CHOICES Group (Group). One of the three groups of TennCare enrollees who are enrolled in ECF CHOICES, and for which a particular package of ECF CHOICES HCBS benefits and limitations pertaining thereto is available. All groups in ECF CHOICES receive services in the community. These Groups are:

(a) Group 4 (Essential Family Supports). Children under age twenty one (21) with I/DD living at home with family who meet the NF LOC and need and are receiving HCBS as an alternative to NF Care, or who, in the absence of HCBS, are "At Risk for Institutionalization, " as defined in these rules, and adults age 21 or older with I/DD living at home with family who meet the NF LOC and need and are receiving HCBS as an alternative to NF care, or who, in the absence of HCBS, are "At Risk for Institutionalization, " as defined in these rules, and elect to be in this group. To qualify in this group, an individual must be SSI eligible or qualify in the ECF CHOICES 217-Like Group, Interim ECF CHOICES At-Risk Demonstration Group, or upon implementation of Phase 2 of ECF CHOICES, the ECF CHOICES At-Risk or ECF CHOICES Working Disabled Demonstration Groups. "Family" shall be interpreted to mean individual(s) to whom the child or adult with I/DD is legally related, whether the relationship is by blood, by marriage, or by adoption. "Family" shall not include a foster care or paid living arrangement.

(b) Group 5 (Essential Supports for Employment and Independent Living). Adults age twenty-one (21) or older with I/DD who do not meet nursing facility level of care, but who, in the absence of HCBS are "At Risk for Institutionalization, " as defined in these rules. To qualify in this group, the adult must be SSI eligible or qualify in the Interim ECF CHOICES At-Risk Demonstration Group, or upon implementation of Phase 2 of ECF CHOICES, the ECF CHOICES At-Risk or ECF CHOICES Working Disabled Demonstration Groups.

(c) Group 6 (Comprehensive Supports for Employment and Community Living). Adults age twenty-one (21) or older with I/DD who meet nursing facility level of care and need and are receiving specialized services for I/DD. To qualify in this group, an individual must be SSI eligible or qualify in the ECF CHOICES 217-Like Demonstration Group, or upon implementation of Phase 2 of ECF CHOICES, the ECF CHOICES Working Disabled Demonstration Group.

(63) ECF CHOICES Home and Community-Based Services (HCBS). Services that are available only to eligible persons enrolled in ECF CHOICES Groups 4, 5 or 6 as an alternative to long-term care institutional services in a nursing facility or to delay or prevent placement in a nursing facility. Only certain ECF CHOICES HCBS are eligible for Consumer Direction. ECF CHOICES HCBS do not include home health or private duty nursing services or any other HCBS that are covered by Tennessee's Title XIX State Plan or under the TennCare demonstration for all eligible enrollees, although such services are subject to estate recovery and shall, for members enrolled in ECF CHOICES Group 6 who are granted an exception to the expenditure cap based on exceptional medical and/or behavioral needs, be counted for purposes of determining whether an ECF CHOICES member's needs can be safely met in the community within his or her individual expenditure cap.

(64) ECF CHOICES Member. A member who has been enrolled by TennCare into ECF CHOICES.

(65) ECF CHOICES Referral List. The listing of Potential Applicants that have completed a screening process to express their interest in applying for enrollment into the ECF CHOICES program.

(66) Electronic Visit Verification (EVV) System. An electronic system into which provider staff and consumer-directed workers can check-in at the beginning and check-out at the end of each period of service delivery to monitor member receipt of specified CHOICES and ECF CHOICES HCBS and which may also be utilized for submission of claims.

(67) Eligible. Any person certified by TennCare as eligible to receive services and benefits under the TennCare program. As it relates to CHOICES and ECF CHOICES a person is eligible to receive CHOICES or ECF CHOICES benefits only if he/she has been enrolled in CHOICES or ECF CHOICES by TennCare. As it relates to the Katie Beckett Program, a person is eligible to receive Katie Beckett Group Part A or Medicaid Diversion Group Part B benefits only if he/she has been enrolled into the applicable Part of the Katie Beckett Program by TennCare.

(68) Eligible CHOICES HCBS. For purposes of CD, CHOICES HCBS that may be consumer-directed are limited to Attendant Care, Personal Care Visits, In-Home Respite Care, or Companion Care. Eligible CHOICES HCBS do not include Home Health or Private Duty Nursing services.

(69) Eligible ECF CHOICES HCBS. Personal assistance, supportive home care, hourly respite, community transportation, and/or any other ECF CHOICES HCBS specified in TennCare rules as eligible for consumer direction which an ECF CHOICES member is determined to need and elects to direct and manage (or have a representative direct and manage) certain aspects of the provision of such services - primarily the hiring, firing and day-to-day supervision of consumer-directed workers delivering the needed service(s) and the delivery of each eligible ECF CHOICES HCBS within the authorized budget for that service. Eligible ECF CHOICES HCBS do not include home health or private duty nursing services.

(70) Eligible Katie Beckett HCBS. Respite, Supportive Home Care, Community Transportation and any other Katie Beckett HCBS specified in TennCare rules as eligible for consumer direction, which a Katie Beckett member is determined to need and which the member's parent or legal guardian elects to direct and manage (or in limited circumstances to have a representative direct and manage) certain aspects of the provision of such services - primarily the hiring, firing and day-to-day supervision of consumer-directed workers delivering the needed service(s) and the delivery of each eligible Katie Beckett HCBS within the authorized budget for that service. Eligible Katie Beckett HCBS do not include home health or private duty nursing services.

(71) Emergent Circumstances. For purposes of reserve capacity in ECF CHOICES, a limited number of individuals who meet one or more emergent circumstances criteria as specified in these Rules and for which enrollment into ECF CHOICES is the most appropriate way to provide needed supports, as determined by an Interagency Review Committee, including both TennCare and DIDD.

(72) Employer of Record. The member participating in consumer direction of eligible CHOICES or ECF CHOICES HCBS or a representative designated by the member to assume the consumer direction of eligible CHOICES or ECF CHOICES HCBS functions on the member's behalf, or the parent or legal guardian of a Katie Beckett Group Part A or Medicaid Diversion Group Part B member participating in consumer direction of eligible Katie Beckett HCBS. In limited circumstances, the parent or legal guardian of a child in Katie Beckett Group Part A or Medicaid Diversion Group Part B may delegate a representative for consumer direction.

(73) Employment and Community First CHOICES (ECF CHOICES). A managed long-term services and supports program that offers home and community-based services to eligible individuals with intellectual and developmental disabilities enrolled in the program in order to promote competitive employment and integrated community living as the first and preferred option.

(74) Employment Informed Choice. The process the MCOs must complete for working age members (ages 16 to 62) enrolled in ECF CHOICES who are eligible for, and want to receive, Community Integration Support Services and/or Independent Living Skills Training services when the member is not engaged in or pursuing integrated employment (with or without Supported Employment Individual or Small Group services, Integrated Employment Path Services or comparable Vocational Rehabilitation/Special Education services). Members who receive Community Living Supports or Community Living Supports-Family Model services are not eligible to receive Community Integration Support Services and/or Independent Living Skills Training services. The Employment Informed Choice process includes, but is not limited to, an orientation to employment, self-employment, employment supports and work incentives provided by the member's support coordinator; the authorization and completion of Exploration services in order to experience various employment settings that are aligned with the member's interests, aptitudes, experiences and/or skills and ensure an informed choice regarding employment; and signed acknowledgment from the member/representative if the member elects not to pursue employment before Community Integration Support Services and/or Independent Living Skills Training may be authorized.

(75) Enhanced Respiratory Care (ERC). Specialized types of assistance provided to individuals with certain significant respiratory care needs as part of the medically necessary services delivered in an appropriately licensed and dual certified NF/SNF, consisting of Ventilator Weaning, Chronic Ventilator Care, or Tracheal Suctioning including Sub-Acute and Secretion Management, and for which a NF may, pursuant to these rules, be eligible to receive Enhanced Respiratory Care Reimbursement.

(76) Enhanced Respiratory Care Reimbursement. Specified levels of reimbursement (i.e., Ventilator Weaning, Chronic Ventilator Care, and Tracheal Suctioning, including Sub-Acute and Secretion Management) provided for ERC delivered by a dual certified NF/SNF that meets the requirements set forth in Rule 1200-13-01-.03(5) to persons determined by the Bureau or an MCO to meet specified medical eligibility or medical necessity criteria for such level of reimbursement.

(77) Enrollee. A TennCare-eligible individual who is enrolled in a TennCare LTSS Program.

(78) Enrollment. One of three (3) components of the referral list management process for ECF CHOICES that occurs only when a Potential Applicant has been determined to meet criteria for an available reserve capacity slot or for one of the categories for which enrollment into ECF CHOICES is currently open, and when there is an appropriate slot available for the person to enroll, subject to all applicable eligibility and enrollment criteria. Enrollment into ECF CHOICES may be approved only by TennCare, and subject to the availability of an appropriate slot for the person to enroll if all applicable eligibility and enrollment criteria are met.

(79) Enrollment Target.

(a) The maximum number of individuals who can be enrolled in CHOICES Group 2 or Group 3, any ECF CHOICES Group, or Katie Beckett Group Part A or Medicaid Diversion Group Part B at any given time, subject to the exceptions provided in this Chapter.

(b) The Enrollment Target is not calculated on the basis of "unduplicated participants." Vacated slots in each group may be refilled immediately, rather than being held until the next program year, as is required in the HCBS Waiver programs.

(c) Persons enrolled in CHOICES Group 2 prior to July 1, 2012, who remain enrolled in CHOICES Group 2 and continue to qualify for TennCare in the CHOICES 1 and 2 Carryover Group shall be counted against the Enrollment Target for CHOICES Group 2.

(80) Expenditure Cap. The annual limit on expenditures for CHOICES or ECF CHOICES that a member enrolled in CHOICES Group 3 or ECF CHOICES, as applicable, can receive. For purposes of the Expenditure Cap for members in CHOICES Group 3 and ECF CHOICES Group 4, the cost of minor home modifications is not counted in calculating annual expenditures for CHOICES HCBS or ECF CHOICES HCBS. For purposes of the Expenditure Cap for members in ECF CHOICES Group 6 who are granted an exception to the Expenditure Cap based on exceptional medical and/or behavioral needs, the cost of home health and private duty nursing shall be counted against the member's Expenditure Cap.

(81) Expiration Date.

(a) A date assigned by the Bureau at the time of approval of a PAE after which TennCare reimbursement will not be made unless a new PAE is submitted and approved, or 365 days after the PAE Approval Date when the PAE has not been used.

(b) A PAE is "used" when the individual has begun receiving LTSS based on the LOC approved in the PAE.

(c) A PAE is "expired" when the individual has not begun receiving LTSS on or before the 365th day or when an assigned approval end date is reached or as specified in 1200-13-01-.10(2)(e).

(d) The first claim for reimbursement may be submitted after the 365th day, so long as the first date of service is on or before the 365th day.

(82) Exploration. For purposes of ECF CHOICES only and limited to persons age 14 or older:

(a) This is a time-limited and targeted service designed to help a person make an informed choice about whether s/he wishes to pursue individualized integrated employment or self-employment, as defined above. The Exploration service shall be completed no more than thirty (30) calendar days from the date of service initiation. This service is not appropriate for ECF CHOICES members who already know they want to pursue individualized integrated employment or self-employment.

(b) This service includes career exploration activities to identify a person's specific interests and aptitudes for paid work, including experience and skills transferable to individualized integrated employment or self-employment. This service also includes exploration of individualized integrated employment or self-employment opportunities in the local area that are specifically related to the person's identified interests, experiences and/or skills through four to five uniquely arranged business tours, informational interviews and/or job shadows. (Each person receiving this service should participate in business tours, informational interviews and/or job shadows uniquely selected based on his or her individual interests, aptitudes, experiences, and skills most transferable to employment. All persons should not participate in the same experiences.) Each business tour, informational interview and/or job shadow shall include time for set-up, prepping the person for participation, and debriefing with the person after each opportunity.

(c) This service also includes introductory education on the numerous work incentives for individuals receiving publicly funded benefits (e.g. SSI, SSDI, Medicaid, Medicare, etc.). This service further includes introductory education on how Supported Employment services work (including Vocational Rehabilitation services). Educational information is provided to the person and the legal guardian/conservator and/or most involved family member(s), if applicable, to ensure legal guardian/conservator and/or family support for the person's choice to pursue individualized integrated employment or self-employment. The educational aspects of this service shall include addressing any concerns, hesitations or objections of the person and the legal guardian/conservator and/or most involved family member(s), if applicable.

(d) This service is expected to involve, on average, forty (40) hours of service. The provider shall document each date of service, the activities performed that day, and the duration of each activity. This service culminates in a written report summarizing the process and outcomes, using a standard template prescribed by TennCare. The written report is due no later than fourteen (14) calendar days after the last date of service is concluded. Exploration is paid on an outcome basis, after the written report is received and approved, and the provider submits documentation detailing each date of service, the activities performed that day, and the duration of each activity.

(e) After an individual has received the service for the first time, re-authorization may occur a maximum of once per year (with a minimum 365-day interval between services) and only if the person, at the time of re-authorization, is not already engaged in individualized integrated employment or self-employment, or other services to obtain such employment.

(83) Family Caregiver Education and Training. For purposes of ECF CHOICES and limited to members enrolled in ECF CHOICES Group 4 (Essential Family Supports) and for purposes of the Katie Beckett Program and limited to children enrolled in Katie Beckett Group Part A or Medicaid Diversion Group Part B:

(a) This service provides reimbursement up to $500 per year to offset the costs of educational materials, training programs, workshops and conferences that help the family caregiver to:

1. Understand the disability of the person supported;

2. Achieve greater competence and confidence in providing supports;

3. Develop and access community and other resources and supports;

4. Develop advocacy skills; and

5. Support the person in developing self-advocacy skills.

(b) Other types of education and training shall not be reimbursed.

(c) Family Caregiver Education and Training is offered only for a family caregiver who is providing unpaid support, training, companionship, or supervision for a person participating in ECF CHOICES who is living in the family home. The intent of the service is to provide education and support to the caregiver that preserves the family unit and increases confidence, stamina and empowerment. Education and training activities are based on the family/caregiver's unique needs and are specifically identified in the person-centered support plan prior to authorization.

(d) In order to be reimbursed by the MCO, Family Caregiver Education and Training must be approved by the member's MCO before such education or training activities commence and shall be limited to no more than $500 per calendar year.

(e) "Family" shall be interpreted to mean individual(s) to whom the child or adult with I/DD is legally related, whether the relationship is by blood, by marriage, or by adoption. "Family" shall not include a foster care or paid living arrangement. Caregiver shall be interpreted as defined in these rules.

(84) Family Caregiver Stipend in lieu of Supportive Home Care. For purposes of ECF CHOICES only and limited to members enrolled in ECF CHOICES Group 4 (Essential Family Supports):

(a) A monthly payment to the primary family caregiver of a person supported when the person lives with the family in the family home and the family is providing daily services and supports that would otherwise be defined within the scope of Supportive Home Care services. This service is available only in lieu of Supportive Home Care (including Personal Assistance) services and shall not be authorized for a person receiving Supportive Home Care (including Personal Assistance) services. The funds may be used to compensate lost wage earning opportunities that are entailed in providing support to a family member with a disability and to help offset the cost of other services and supports the person needs that are not covered under this program.

(b) For a child under age 18, the Family Caregiver Stipend shall be limited to $500 per month. For an adult age 18 or older, the Family Caregiver Stipend shall be no more than $1, 000 per month. The amount of Family Caregiver Stipend approved shall be based on the needs of the individual taking into account the supports necessary for employment and community integration and participation, and shall ensure that supports necessary for employment and community integration and participation are provided first, or available to the person through other sources (whether paid or unpaid) or as part of the supports provided by the family caregiver in order for a Stipend to be approved.

(c) "Family" shall be interpreted to mean individual(s) to whom the child or adult with I/DD is legally related, whether the relationship is by blood, by marriage, or by adoption. "Family" shall not include a foster care or paid living arrangement. Caregiver shall be interpreted as defined in these rules.

(85) Family-to-Family Support. For purposes of ECF CHOICES and limited to members enrolled in ECF CHOICES Group 4 (Essential Family Supports) and for purposes of the Katie Beckett Program and limited to children enrolled in Katie Beckett Group Part A or Medicaid Diversion Group Part B:

(a) These services provide information, resources, guidance, and support from an experienced and trained parent or other family member to another parent or family caregiver who is the primary unpaid support to a child with intellectual or developmental disabilities enrolled in ECF CHOICES. The service shall include facilitation of parent or family member "matches" and follow-up support to assure the matched relationship meets peer expectations.

(b) Family-to-Family Support shall be reimbursed on a per member per month basis for each Member enrolled in ECF CHOICES Group 4 and Katie Beckett Part Group A and Medicaid Diversion Group Part B. The per member per month reimbursement of Family-to-Family Support shall not be counted against the member's expenditure cap or for children enrolled in Katie Beckett Group Part A, the comparable cost of institutional care requirement.

(86) Federal Estate Recovery Program (FERP). A federal program set forth under Section 1917(b) of the Social Security Act that requires states offering Medicaid-reimbursed LTSS to seek adjustment or recovery for certain types of medical assistance from the estates of individuals who were age fifty-five (55) or older at the time such assistance was received, and from permanently institutionalized individuals of any age. For both mandatory populations, the State may elect to recover up to the total cost of all medical assistance provided.

(a) For persons age fifty-five (55) and older, the State is obligated to seek adjustment or recovery for NF (including ICF/IID) services, HCBS, and related hospital and prescription drug services.

(b) For permanently institutionalized persons, states are obligated to seek adjustment or recovery for the institutional services.

(87) Fee-for-Service (FFS) System. An arrangement whereby the Bureau, rather than the MCO, is responsible for arranging for covered LTSS and paying claims for these services.

(88) Fiscal Employer Agent (FEA). An entity contracting with the State and/or one of the State's contracted MCOs that helps CHOICES, ECF CHOICES, and Katie Beckett Group Part A and Medicaid Diversion Group Part B members participating in consumer direction of eligible CHOICES, ECF CHOICES, or Katie Beckett HCBS. The FEA provides both financial administration and supports brokerage functions for CHOICES and ECF CHOICES members participating in consumer direction of eligible CHOICES or ECF CHOICES HCBS and parents or legal guardians of Katie Beckett Group Part A and Medicaid Diversion Group Part B members participating in consumer direction of eligible Katie Beckett HCBS. This term is used by the IRS to designate an entity operating under Section 3504 of the IRS code, Revenue Procedure 70-6 and Notice 2003-70, as the agent to members for the purpose of filing certain federal tax forms and paying federal income tax withholding, FICA and FUTA taxes. The FEA also files state income tax withholding and unemployment insurance tax forms and pays the associated taxes and processes payroll based on the eligible CHOICES, ECF CHOICES, or Katie Beckett HCBS authorized and provided.

(89) Grand Divisions. See "Grand Divisions" in Rule 1200-13-13-.01.

(90) Health Care Tasks. For CHOICES Members participating in CD, those medical, nursing, or HH Services, beyond ADLs, that:

(a) A person without a functional disability or a caregiver would customarily perform without the assistance of a licensed health care provider;

(b) The person is unable to perform for himself due to a functional or cognitive limitation;

(c) The treating physician, advanced practice nurse, or registered nurse determines can safely be performed in the home and community by an unlicensed Consumer-Directed Worker under the direction of a Competent Adult or caregiver; and

(d) Enable the person to maintain independence, personal hygiene, and safety in his own home.

(91) Health Insurance Counseling/Forms Assistance. For purposes of ECF CHOICES and limited to members enrolled in ECF CHOICES Group 4 (Essential Family Supports) and for purposes of the Katie Beckett Program and limited to children enrolled in Katie Beckett Group Part A or Medicaid Diversion Group Part B:

(a) Health Insurance Counseling/Forms Assistance services offers training and assistance to individuals enrolled in ECF CHOICES and/or their family caregiver and policy holder in understanding the benefits offered through their private or public insurance program, completing necessary forms, accessing covered benefits, and navigating member appeal processes regarding covered benefits. An insurance company or its affiliate shall not be reimbursed for providing this service.

(b) This is a time-limited service intended to develop the person and/or family caregiver's understanding and capacity to self-manage insurance benefits. Reimbursement shall be limited to 15 hours per person per year.

(c) Persons choosing to receive this service must agree to complete an online assessment of its efficacy following the conclusion of counseling and/or forms assistance.

(92) Home and Community-Based Services (HCBS). Services that are provided pursuant to a Section 1915(c) Waiver or the CHOICES, ECF CHOICES, or Katie Beckett program as an alternative to long-term care institutional services in a nursing facility or an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) or to delay or prevent placement in a nursing facility. HCBS may also include optional or mandatory services that are covered by Tennessee's Title XIX State Plan or under the TennCare demonstration for all eligible enrollees, including home health or private duty nursing. However, only specified CHOICES, ECF CHOICES, and Katie Beckett HCBS are eligible for Consumer Direction. CHOICES, ECF CHOICES, and Katie Beckett HCBS do not include home health or private duty nursing services or any other HCBS that are covered by Tennessee's Title XIX State Plan or under the TennCare demonstration for all eligible enrollees, although such services are subject to estate recovery and shall be counted for purposes of determining whether a CHOICES Group 2 member's needs can be safely met in the community within his or her individual cost neutrality cap, and whether the Comparable Cost of Institutional Care Requirement is met in order for a child to qualify for enrollment in Katie Beckett Group Part A or the Continued Eligibility Group Part C. The cost of home health and private duty nursing shall also be counted against the member's Expenditure Cap for members in ECF CHOICES Group 6 who are granted an exception to the Expenditure Cap based on exceptional medical and/or behavioral needs.

(93) Home and Community Based Services (HCBS) Waiver. A Waiver approved by CMS under the Section 1915(c) authority.

(94) Home-Delivered Meals.

(a) Nutritionally well-balanced meals, other than those provided under Title III C-2 of the Older Americans Act, that provide at least one-third but no more than two-thirds of the current daily Recommended Dietary Allowance (as estimated by the Food and Nutrition Board of Sciences - National Research Council) and that will be served in the Enrollee's home. Special diets shall be provided in accordance with the individual POC when ordered by the Enrollee's physician.

(b) Regardless of payer, Home-Delivered Meals shall not be provided to Members living in an ACLF, Adult Care Home, Residential Home for the Aged or other group residential setting, or receiving CBRA (including Companion Care) or Short-Term NF services, provided however, that an MCO may authorize Home-Delivered Meals for a CHOICES member receiving Companion Care or Community Living Supports (not Community Living Supports-Family Model) in their own home (not a provider-controlled residence) when such service is medically necessary in order to 1) address health risks related to food insecurity; 2) support improved management of chronic health conditions; 3) reduce risk of hospital readmissions related to such chronic health conditions; 4) improve physical or mental health outcomes; or 5) delay or prevent nursing home placement.

(95) Home Health (HH) Services. See "Home Health Services" in Rule 1200-13-13-.01.

(96) Homemaker Services.

(a) General household activities and chores such as sweeping, mopping, and dusting in areas of the home used by the Member, changing the Member's linens, making the Member's bed, washing the Member's dishes, doing the Member's personal laundry, ironing or mending, meal preparation and/or educating caregivers about preparation of nutritious meals for the Member, assistance with maintenance of a safe environment, and errands such as grocery shopping and having the Member's prescriptions filled.

(b) Provided only for the Member (and not for other household members) and only when the Member is unable to perform such activities and there is no other caregiver or household member available to perform such activities for the Member.

(c) Effective July 1, 2012, provided only as part of Personal Care Visits and Attendant Care services for Members who also require hands-on assistance with ADLs. Homemaker Services authorized in an approved POC on or before June 30, 2012, shall continue to be provided for no more than ninety (90) days after July 1, 2012, pending a reassessment of the Member's needs and modifications to the Member's POC to comport with the new benefit structure, as well as individual notice of action, when required. Homemaker Services shall not be continued pending resolution of any appeal filed on or after July 1, 2012, as Homemaker Services are no longer covered as a stand-alone benefit. Homemaker Services are not covered for anyone who does not also require hands-on assistance with ADLs.

(d) Regardless of payer, shall not be provided to Members living in an ACLF, Adult Care Home, Residential Home for the Aged or other group residential setting, or receiving CBRA (including Companion Care) or Short-Term NF services.

(97) ICF/IID Eligible. An individual determined by DHS to qualify for Medicaid ICF/IID services and determined by the Bureau to meet the ICF/IID LOC.

(98) ICF/IID PAE Effective Date. The beginning date of LOC eligibility for Medicaid-reimbursed care in an ICF/IID or HCBS Waiver services offered as an alternative to care in an ICF/IID, for which the ICF/IID PAE has been approved by the Bureau.

(99) ICF/IID PAE Form. The assessment form used by the Bureau to document the current medical and habilitative needs of an individual with MR and to document that the individual meets the Medicaid LOC eligibility criteria for care in an ICF/IID.

(100) Identification Screen (Level I). See "PreAdmission Screening/Resident Review."

(101) Immediate Family Member. For purposes of employment as a Consumer-Directed Worker in CHOICES and in CHOICES Community Living Supports-Family Model, a spouse, parent, grandparent, child, grandchild, sibling, mother-in-law, father-in-law, sister-in-law, brother-in-law, daughter-in-law, and son-in-law. Adopted and step Members are included in this definition.

(102) Independent Living Skills Training. For purposes of ECF CHOICES only:

(a) Independent Living Skills Training services provide education and skill development or training to improve the person's ability to independently perform routine daily activities and utilize community resources as specified in the person's person-centered support plan. Services are instructional, focused on development of skills identified in the person-centered support plan and are not intended to provide substitute task performance. Daily living skills training may include only education and skill development related to:

1. Personal hygiene;

2. Food and meal preparation;

3. Home upkeep/maintenance;

4. Money management;

5. Accessing and using community resources;

6. Community mobility;

7. Parenting;

8. Computer use; and

9. Driving evaluation and lessons.

(b) Independent Living Skills Training is intended as a short-term service designed to allow a person not receiving Community Living Supports or Community Living Supports-Family Model to acquire specific additional skills that will support his/her transition to or sustained independent community living. Individuals receiving Independent Living Skills Training must have specific independent-living goals in their person-centered support plan that Independent Living Skills Training is specifically designed to support.

(c) The provider must prepare and follow a specific plan and strategy for teaching specific skills for the independent living goals identified in the person-centered support plan. Systematic instruction and other strategies used in Supported Employment Job Coaching should also be employed in this service. The provider must document monthly progress toward achieving each independent living skill identified in the person-centered support plan.

(d) This service will typically originate from the person's home and take place in the person's home and home community. Providers of this service should meet people in these natural environments to provide this service rather than maintaining a separate service location.

(e) Transportation during the service (when no-cost forms of transportation are not available or not being accessed) is included in the rate paid for the service.

(f) Individuals receiving Community Living Supports or Community Living Supports-Family Model are not eligible to receive this service, since the scope of benefits provided to a person under the CLS and CLS-FM benefits include habilitation training and supports to help the person achieve maximum independence and sustained community living.

(g) Independent Living Skills Training shall be limited as follows:

1. For persons not working in Individualized Integrated Employment, Individualized Integrated Self-Employment, or Small Group Employment in the community or receiving at least one employment service, no more than 20 hours per week of Independent Living Skills Training and Community Integration Support Services combined after completing an Employment Informed Choice process.

2. For persons who are working in Individualized Integrated Employment, Individualized Integrated Self-Employment, or Small Group Employment in the community (not a sheltered workshop) or receiving at least one employment service, no more than 30 hours per week of Independent Living Skills Training, Community Integration Support Services, and Individual or Small Group Employment Supports combined.

3. For persons who are working in Individualized Integrated Employment or Individualized Integrated Self-Employment (not in a small group or in a sheltered workshop), no more than 40 hours per week of Independent Living Skills Training, Community Integration Support Services, Job Coaching, Co-Worker Supports, and the hours worked without paid supports combined.

4. For persons who are working in Individualized Integrated Employment or Individualized Integrated Self-Employment (not in a small group or in a sheltered workshop) at least 30 hours per week, no more than 50 hours per week of Independent Living Skills Training, Community Integration Support Services, Job Coaching, Co-Worker Supports, and the hours worked without paid supports combined.

(103) Individual Acuity Score. The weighted value assigned by TennCare to:

(a) The response to a specific ADL or related question in the PAE for NF LOC that is supported by the medical evidence submitted with the PAE; or

(b) A specific skilled or rehabilitative service determined by TennCare to be needed by the applicant on a daily basis or at least five (5) days per week for rehabilitative services based on the medical evidence submitted with the PAE and for which TennCare would authorize level 2 or Enhanced Respiratory Care Reimbursement in a NF.

(c) An Individual Acuity Score shall be based only on the response to the specific ADL or related question on the PAE, and the supporting medical evidence submitted with the PAE pertaining to such question on the PAE, and not by any other assessment instrument, including the adaptive behavior (or life skills) assessment used to determine whether a person has an intellectual or developmental disability; provided, however, that all available information, including the adaptive behavior (or life skills) assessment shall be taken into account in a Safety Determination (see Rule 1200-13-01-.02 and Rule 1200-13-01-.05(6)).

(104) Individual Cost Neutrality Cap. See "Cost Neutrality Cap."

(105) Individual Education and Training Services. For purposes of ECF CHOICES only and limited to members enrolled in ECF CHOICES Group 5 (Essential Supports for Employment and Independent Living) or Group 6 (Comprehensive Supports for Employment and Community Living):

Reimbursement up to $500 per year to offset the costs of training programs, workshops and conferences that help the person develop self-advocacy skills, exercise civil rights, and acquire skills needed to exercise control and responsibility over other support services. Other types of education and training shall not be reimbursed. This service may include education and training for participants, their caregivers and/or legal representatives that is directly related to building or acquiring such skills. Managed care organizations assure that information about educational and/or training opportunities is available to participants and their caregivers and legal representatives. Covered expenses may include enrollment fees, books and other educational materials and transportation related to participation in training courses, conferences and other similar events. In order to be reimbursed by the MCO, Individual Education and Training Services must be approved by the member's MCO before such education or training activities commence and shall be limited to $500 per individual per calendar year.

(106) Individualized Integrated Employment. Sustained paid employment in a competitive or customized job with an employer for which an individual is compensated at or above the state's minimum wage, with the optimal goal being not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities.

(107) Individualized Integrated Self-Employment. Sustained paid self-employment that is home-based or conducted in an integrated setting(s) where net income in relation to hours worked is equivalent to no less than the state's minimum wage, after a reasonable self-employment start-up period.

(108) Individualized Therapeutic Support Reimbursement. For purposes of the Katie Beckett Program only and limited to children enrolled in Medicaid Diversion Group Part B:

(a) Reimbursement, using DIDD's contracted vendor, of therapeutic supports determined by DIDD to be medically necessary for the child, but not eligible for automated reimbursement as part of the Automated Health Care and Related Expenses Reimbursement benefit.

(b) Limited to the amount specified in the child's DIDD-approved ISP and subject to the $10, 000 per child per year limit on total benefits available through Medicaid Diversion Group Part B.

(c) Each type and amount of therapeutic support shall be requested and approved by DIDD as part of the child's ISP in advance of such support being purchased.

(d) In order to be covered and eligible for reimbursement, the child's parent or legal guardian shall submit acceptable documentation to DIDD, confirming that the approved therapeutic support has been received and paid, and is eligible for reimbursement. The child's parent or legal guardian shall comply with all applicable DIDD requirements in order to receive this benefit.

(e) A period of ninety (90) days shall be provided at the end of each year for submission of final expenditures incurred.

(f) Any funds remaining in the child's Individualized Therapeutic Support Reimbursement benefit at the end of the year shall be forfeited to the Katie Beckett program and shall not be permitted to "roll over" to the next year.

(109) In-Home Respite Care. For purposes of CHOICES:

(a) Services provided to Members unable to care for themselves, furnished on a short-term basis in the Member's place of residence, because of the absence or need for relief of those family members or other unpaid caregivers normally providing the care; and

(b) Regardless of payer, shall not be provided to Members living in an ACLF, Adult Care Home, Residential Home for the Aged or other group residential setting, or receiving CBRA (including Companion Care) or Short-Term NF services.

(110) Initial Support Plan (SP). As it pertains to ECF CHOICES, the Initial SP is a written plan developed by the Support Coordinator in accordance with policies and protocols established by TennCare which identifies ECF CHOICES HCBS that are needed by the ECF CHOICES member immediately upon enrollment in ECF CHOICES while the Support Coordinator develops the comprehensive Person-Centered Support Plan. Needed ECF CHOICES HCBS specified in the Initial SP shall be authorized for no more than thirty (30) calendar days, by which point the MCO shall develop and implement the member's comprehensive Person-Centered Support Plan.

(111) Inpatient Nursing Care. Nursing services that are available twenty-four (24) hours per day by or under the supervision of a licensed practical nurse or registered nurse and which, in accordance with general medical practice, are usually and customarily provided on an inpatient basis in a NF. Inpatient Nursing Care includes, but is not limited to, routine nursing services such as observation and assessment of the individual's medical condition, administration of legend drugs, and supervision of nurse aides; and other skilled nursing therapies or services that are performed by a licensed practical nurse or registered nurse.

(112) Inpatient Respite Care. For purposes of CHOICES:

(a) Services provided to individuals unable to care for themselves, furnished on a short-term basis in a licensed NF or licensed CBRA facility, because of the absence or need for relief of those family members or other unpaid caregivers normally providing the care.

(b) Regardless of payer, shall not be provided to Members living in an ACLF, Adult Care Home, Residential Home for the Aged or other group residential setting, or receiving CBRA (including Companion Care) or Short-Term NF services.

(113) Institutional Personal Needs Allowance. See "Personal Needs Allowance (PNA)."

(114) Intake. One of three (3) components of the referral list management process for ECF CHOICES during which basic documentation is gathered to confirm information self-reported in the screening process, including whether a person has an intellectual or developmental disability (i.e., is in the target population for ECF CHOICES) and other information that will be used to prioritize the person for enrollment into ECF CHOICES based on established prioritization and enrollment criteria. Intake is generally performed during a face-to-face interview with the Potential Applicant. The result of intake could be 1) a decision to proceed with enrollment because a person with ID qualifies for an available reserve capacity slot based on an aging caregiver or meets certain prioritization criteria for a category for which enrollment is open and there is an appropriate slot available for enrollment; 2) referral to the Interagency Review Committee because the person may meet criteria for a reserve capacity slot based on emergent circumstances or multiple complex health conditions; or 3) continued placement on the ECF CHOICES referral list in the appropriate category.

(115) Integrated Employment Path Services (Time-Limited, Community-Based Prevocational Training). For purposes of ECF CHOICES only and limited to members age 16 or older:

(a) The provision of time-limited learning and work experiences, including volunteering opportunities, where a person can develop general, non-job-task-specific strengths and skills that contribute to employability in individualized integrated employment or self-employment. Services are expected to specifically involve strategies that facilitate a participant's successful transition to individualized integrated employment or self-employment.

(b) Individuals receiving Integrated Employment Path Services must have a desire to obtain some type of individualized integrated employment or self-employment and this goal must be documented in the PCSP as the goal that Integrated Employment Path Services are specifically authorized to address.

(c) Services should be customized to provide opportunities for increased knowledge, skills and experiences specifically relevant to the person's specific individualized integrated employment and/or self-employment goals and career goals. If such specific goals are not known, this service can also be used to assist a person with identifying his/her specific individualized integrated employment and/or self-employment goals and career goals.

(d) The expected outcome of this service is measurable gains in knowledge, skills and experiences that contribute to the individual achieving individualized integrated employment or self-employment. Integrated Employment Path Services are intended to develop and teach general skills that lead to individualized integrated employment or self-employment including but not limited to: ability to communicate effectively with supervisors, co-workers and customers; generally accepted community workplace conduct and dress; ability to follow directions; ability to attend to tasks; workplace problem solving skills and strategies; and general workplace safety and mobility training.

(e) Service limitations:

1. This service is limited to no more than twelve (12) months. One extension of up to twelve (12) months can be allowed only if the individual is actively pursuing individualized integrated employment or self-employment in an integrated setting and has documentation that a service(s) (i.e. Job Development or Self-Employment Start-Up funded by Tennessee Rehabilitation Services, ECF CHOICES or another similar source) is concurrently authorized for this purpose. The twelve (12) month authorization and one twelve (12) month reauthorization may be repeated only if a person loses individualized integrated employment or self-employment and is seeking replacement opportunities.

2. This service must be delivered in integrated, community settings and may not be provided in sheltered workshops or other segregated facility-based day, vocational or prevocational settings.

3. Integrated Employment Path Services shall not be provided or reimbursed if the person is receiving Job Coaching (for Individualized Integrated Employment or Self-Employment), Co-Worker Supports or is working in individualized integrated employment or self-employment without any paid supports. Integrated Employment Path Services are only appropriate for individuals who are not yet engaged in individualized integrated employment or self-employment.

4. Integrated Employment Path Services shall be limited to no more than 30 hours per week in combination with Supported Employment - Small Group, Community Integration Support Services, and Independent Living Skills Training.

(f) Transportation of the individual to and from this service is not included in the rate paid for this service but transportation during the service is included in the rate.

(g) ECF CHOICES will not cover services which are otherwise available to the individual under Section 110 of the Rehabilitation Act of 1973, or the IDEA (20 U.S.C. §§ 1401, et seq.). If this service is authorized, documentation is maintained that the service is not available to the individual under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. §§ 1401, et seq.).

(h) This service will not duplicate other services provided through the Waiver or Medicaid State Plan services.

(116) Intellectual Disability(ies) (ID). Pursuant to T.C.A. § 33-1-101, an intellectual disability is defined as substantial limitations in functioning:

(a) As shown by significantly sub-average intellectual functioning that exists concurrently with related limitations in two (2) or more of the following adaptive skill areas: communication, self-care, home living, social skills, community use, self-direction, health and safety, functional academics, leisure, and work; and

(b) That are manifested before eighteen (18) years of age.

For purposes of ECF CHOICES, the determination that an Applicant has limitations in two (2) or more adaptive skill areas shall be made by TennCare using an adaptive behavior (or life skills) assessment tool, and review of supporting medical evidence. Information gathered through such adaptive behavior (or life skills) assessment shall not be used for purposes of evaluating functional deficits described in Rule 1200-13-01-.10, or in determining an Individual Acuity Score or an Applicants total score on the NF LOC Acuity Scale.

(117) Interagency Review Committee. The committee composed of staff from TennCare and DIDD that reviews requests submitted on behalf of a Potential Applicant in order to determine whether the Potential Applicant meets emergent circumstances or multiple complex health conditions criteria as defined in these rules. A determination by the Interagency Review Committee that a Potential Applicant meets emergent circumstances or multiple chronic health conditions criteria shall be required before DIDD or an MCO proceeds with an enrollment visit to determine if the Potential Applicant qualifies to enroll in ECF CHOICES in a reserve capacity slot designated for such purpose.

(118) Interim CHOICES Group 3 (open only between July 1, 2012, and June 30, 2015).

(a) Individuals age sixty-five (65) and older and adults age twenty-one (21) and older with Physical Disabilities who qualify for TennCare as SSI recipients or as Members of the CHOICES At-Risk Demonstration Group, and who are At Risk for Institutionalization as defined in these rules. There will be no Enrollment Target applied to Interim CHOICES Group 3.

(b) Members enrolled in Interim CHOICES Group 3 on June 30, 2015, may continue to qualify in this group after June 30, 2015, so long as they continue to meet NF financial eligibility, continue to be At Risk for Institutionalization, can be safely served in Interim CHOICES Group 3, and remain continuously enrolled in the CHOICES At-Risk Demonstration Group and in CHOICES Group 3.

(119) Interim ECF CHOICES At-Risk Group. Individuals with I/DD of all ages who: are not eligible for Medicaid or TennCare under any other category; meet the financial eligibility standards for the ECF CHOICES 217-Like Group; do not meet NF LOC criteria but in the absence of ECF CHOICES, are At Risk for Institutionalization. The Interim ECF CHOICES At Risk Demonstration Group will open to new enrollment only until such time that the Employment and Community First CHOICES At-Risk Demonstration Group (with income up to one hundred and fifty percent (150%) of the FPL) and the Employment and Community First CHOICES Working Disabled Demonstration Groups can be established. Persons enrolled in the Interim ECF CHOICES At-Risk Demonstration Group as of the date new enrollment into the group closes may continue to qualify in the group as long as they continue to meet nursing facility financial eligibility standards and the At-Risk LOC criteria, and remain continuously eligible and enrolled in the Interim ECF CHOICES At-Risk Demonstration Group. Enrollment in this group shall be subject to the enrollment targets established for each applicable ECF CHOICES benefit group. An Applicant may qualify in the Interim ECF CHOICES At-Risk Group only when there is an available slot for enrollment into an ECF CHOICES benefit group for which the Applicant meets all eligibility and enrollment criteria, including prioritization criteria for enrollment into ECF CHOICES as established in these Rules, and when the Applicant, upon approval of financial eligibility, will be enrolled by TennCare into such ECF CHOICES group.

(120) Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) (formerly and also known as Intermediate Care Facility for persons with Mental Retardation or ICF/MR). A licensed facility approved for Medicaid reimbursement that provides specialized services for individuals with ID or related conditions and that complies with current federal standards and certification requirements set forth in 42 C.F.R., Part 483.

(121) Involuntary Transfer or Discharge. Any transfer or discharge that is opposed by the resident or a Representative of the resident of a NF or ICF/IID. For purposes of compliance with the requirements of this Chapter, a discharge or transfer is involuntary when the NF initiates the action to transfer or discharge.

(122) Job Coaching. For purposes of ECF CHOICES only and limited to members age 16 or older:

(a) Job Coaching for Individualized, Integrated Employment includes identifying, through job analysis, and providing services and supports that assist the individual in maintaining individualized integrated employment that pays at least minimum wage but ideally not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. Job coaching includes supports provided to the individual and his/her supervisor and/or co-workers, either remotely (via technology) or face-to-face. Supports during each phase of employment must be guided by a Job Coaching Fading Plan which incorporates an appropriate mix of best practices for the individual to achieve fading goals as identified in the Plan (e.g. systematic instruction utilizing task analysis to teach the individual to independently complete as much of his/her job duties as possible; high or low tech assistive technology; and effective engagement of natural supports including co-workers and supervisor(s) as needed). If progress on fading ceases at some point, adaptations to job duties, negotiated with the supervisor/employer, or transition to Co-Worker Supports may be utilized if no reduction in hours or hourly pay results.

1. The amount of time authorized for this service is a percentage of the individual's hours worked and is tiered based on the individual's level of disability and the length of time the person has been employed on the job. An exception policy applies for individuals with exceptional circumstances.

2. Transportation of the supported employee to and from the job site is not included in the rate paid for the service. Transportation of the supported employee, if necessary, during the provision of job coaching is included in the rate paid for the service.

(b) Job Coaching for Individualized, Integrated Self-Employment includes identification and provision of services and supports that assist the individual in maintaining self-employment. Job coaching for self-employment includes supports provided to the individual, either remotely (via technology) or face-to-face. Supports must enable the individual to successfully operate the business (with assistance from other sources of professional services or suppliers of goods necessary for the type of business). Job Coaching supports should never supplant the individual's role or responsibility in all aspects of the business. Supports during each phase of self-employment must be guided by a Job Coaching Fading Plan which incorporates an appropriate mix of best practices for the individual to achieve fading goals as identified in the Plan (e.g., systematic instruction utilizing task analysis to teach the individual to independently complete as much of his/her roles and responsibilities as possible; high or low tech assistive technology; and effective engagement of any business partners and/or associates and/or suppliers of goods or services. If progress on fading ceases at some point, business plan adaptations may be utilized if no reduction in paid hours or net hourly pay results.

1. The amount of time authorized for this service is a percentage of the individual's hours engaged in self-employment and is tiered based on the individual's level of disability and the length of time the person has been self-employed in the current business. An exception policy applies for individuals with exceptional circumstances.

2. Transportation of the supported self-employed person to and from the place of work is not included in the rate paid for the service. Transportation of the supported self-employed person, if necessary, during the provision of job coaching is included in the rate paid for the service.

(c) Job Coaching (for Individualized, Integrated Employment or Individualized, Integrated Self-Employment) shall be limited as follows:

1. No more than 40 hours per week of Job Coaching, Co-Worker Supports, Community Integration Support Services, Independent Living Skills Training, and the hours worked without paid supports combined.

2. For persons who are working in Individualized Integrated Employment or Individualized Integrated Self-Employment (not in a small group or in a sheltered workshop) at least 30 hours per week, no more than 50 hours per week of Job Coaching, Co-Worker Supports, Community Integration Support Services, Independent Living Skills Training, and the hours worked without paid supports combined.

(123) Job Development or Self-Employment Start Up. For purposes of ECF CHOICES only and limited to members age 16 or older:

(a) This is a time-limited service designed to implement a Job Development or Self-Employment Plan as follows:

1. Job Development is support to obtain an individualized competitive or customized job in an integrated employment setting in the general workforce, for which an individual is compensated at or above the minimum wage, but ideally not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. The Job Development strategy should reflect best practices and be adjusted based on whether the individual is seeking competitive or customized employment.

2. Self-Employment Start Up is support in implementing a self-employment business plan. The outcome of this service is expected to be the achievement of an individualized integrated employment or self-employment outcome consistent with the individual's personal and career goals, as determined through Exploration, Discovery and/or the Situational Observation and Assessment, if authorized, and as identified in the Job Development or Self-Employment Plan that guides the delivery of this service.

(b) This service will be paid on an outcome basis once the person has completed two calendar weeks of individualized integrated employment or self-employment. Outcome payment amounts are tiered based upon the assessed level of challenge anticipated to achieve the intended outcome of this service for the individual being served. Outcome payments are also paid over three phases to incentivize retention of the job or self-employment situation.

(c) After an individual has received the service for the first time, re-authorization may occur a maximum of once per year (with a minimum 365-day interval between services), and only if the person, at the time of re-authorization, is not already engaged in individualized integrated employment or self-employment, or other services to obtain such employment, and the person has a goal to obtain individualized integrated employment or self-employment within nine (9) months.

(124) Job Development Plan or Self-Employment Plan. For purposes of ECF CHOICES only and limited to members age 16 or older:

(a) This is a time-limited and targeted service designed to create a clear and detailed plan for Job Development or for the start-up phase of Self-Employment. This service is limited to thirty (30) calendar days from the date of service initiation. This service includes a planning meeting involving the individual and other key people who will be instrumental in supporting the individual to become employed in individualized integrated employment or self-employment.

(b) This service culminates in a written plan, using a template prescribed by TennCare, that incorporates the results of Exploration, Discovery, and/or Situational Observation and Assessment, if previously authorized. The written plan is due no later than thirty (30) calendar days after the service commences. For self-employment goals, this service results in the development of a self-employment business plan, including potential sources of business financing (such as VR, Small Business Administration loans, PASS plans), given that Medicaid funds may not be used to defray the capital expenses associated with starting a business. This service is paid on an outcome basis, after the written plan is received and approved, and the provider submits documentation detailing each date of service, the activities performed that day, and the duration of each activity.

(c) After an individual has received the service for the first time, re-authorization may occur a maximum of once every three years (with a minimum of three 365-day intervals between services), and only if the person, at the time of re-authorization, is not already engaged in individualized integrated employment or self-employment, or other services to obtain such employment, and the person has a goal to obtain individualized integrated employment or self-employment within twelve (12) months.

(125) Katie Beckett Group Part A. The component of Tennessee's Katie Beckett Program that serves a limited number of children with the most significant disabilities or complex medical needs who meet institutional level of care, as established by TennCare, and who qualify for Medicaid only by waiving the deeming of parents' income and/or assets to the child. Children enrolled by TennCare into Katie Beckett Group Part A are eligible to receive all covered, medically necessary Medicaid benefits, including benefits provided under the EPSDT program as well as case management and specified wraparound HCBS not otherwise covered by the Medicaid program, including respite. Initial and ongoing enrollment in Katie Beckett Group Part A will consist of children who are under age 18 who (1) have medical needs that are likely to last at least twelve months or result in death; and result in severe functional limitations based on medical eligibility criteria developed by TennCare specifically for children; (2) qualify for care in a medical institution; (3) qualify for supplemental security income (SSI) due the child's disability, except for the parent's income and/or assets; (4) have received certification from a licensed physician that in-home care will meet the child's needs; (5) the cost of providing the child's care at home, including traditional Medicaid benefits and wraparound HCBS, cannot exceed the estimated Medicaid cost of institutional care; and (6) is not Medicaid-eligible or receiving long-term services and supports in another Medicaid program. Upon turning age eighteen (18), individuals enrolled in Katie Beckett Group Part A may remain enrolled in Katie Beckett Group Part A for up to twelve (12) months following the enrollee's eighteenth (18th) birthday if an application for SSI is pending or in appeal status.

(126) Katie Beckett Group Part A Member. A member who has been enrolled by TennCare into Katie Beckett Group Part A of the Katie Beckett Program.

(127) Katie Beckett Home and Community Based Services (HCBS). Specified services that are available only to eligible children enrolled in Katie Beckett Group Part A or specified services that are available only to eligible children enrolled in Medicaid Diversion Group Part B. Katie Beckett Part A and Part B HCBS are sometimes called wraparound services or wraparound HCBS because they "wrap around" a chid's primary health insurance and/or Medicaid EPSDT benefits, as applicable, offering specifically defined additional benefits not typically covered by TennCare in order to help child in the home and community-based setting. Only certain Katie Beckett Group Part A or Medicaid Diversion Group Part B HCBS are eligible for Consumer Direction (see Eligible Katie Beckett HCBS). Katie Beckett Group Part A and Medicaid Diversion Group Part B HCBS do not include home health or private duty nursing services or any other HCBS that are covered by Tennessee's Title XIX State Plan or under the TennCare demonstration for all eligible children, although such services shall be counted for purposes of determining whether a child meets the comparable cost of institutional care requirement as defined in this rule in order to qualify for enrollment in Katie Beckett Group Part A or the Continued Eligibility Group Part C.

(128) Katie Beckett Program. A TennCare demonstration program authorized by T.C.A. § 71-5-164 that offers services and supports as defined in these rules to children under age 18 with disabilities and/or complex medical needs who are not Medicaid eligible because of their parents' income or assets. There are three (3) distinct groups described and defined in this rule:

(a) Katie Beckett Group Part A

(b) Medicaid Diversion Group Part B

(c) Continued Eligibility Group Part C

(129) Legal Guardian. For purposes of the Katie Beckett Program, the individual with physical custody of the child and the legal authority to make decisions concerning the child's protection, education, care, medical treatment, etc., including the child's PCSP for Katie Beckett Group Part A and DIDD-approved ISP for Medicaid Diversion Group Part B. Generally, the child's parent is the legal guardian except when guardianship has been otherwise established through court proceedings.

(130) Legally Appointed Representative. Any person appointed by a court of competent jurisdiction or authorized by legal process (e.g., power of attorney for health care treatment, declaration for mental health treatment) to determine the legal and/or health care interests of an individual and/or his estate.

(131) Level of Care (LOC). Medical eligibility criteria for receipt of an institutional service, HCBS offered as an alternative to the institutional service, or in the case of persons At Risk for Institutionalization, to delay or prevent institutional placement. An individual who meets the LOC criteria for a particular LTSS program or service is an individual who has been determined by TennCare to meet the medical eligibility criteria established for that service.

(132) Level of Need. The categorization of the intensity level of practical supports needed by a member enrolled in ECF CHOICES Group 6 based on an objective assessment utilizing the American Association of Intellectual and Developmental Disabilities Supports Intensity Scale®. The member's assessed level of need, including consideration of exceptional medical or behavioral needs as identified in the assessment, is used to establish the member's Expenditure Cap, required Support Coordinator-to-member ratios, and frequency of required Support Coordination contacts in the ECF CHOICES program.

(133) Linton. The lawsuit known as Linton v. Tennessee Commissioner of Health and Environment resulting in a series of Orders issued by the United States District Court and the Sixth Circuit Court of Appeals regarding NF services.

(134) Long-Term Care (LTC) Ombudsman. An individual with expertise and experience in the fields of LTSS and advocacy, who assists in the identification, investigation, and resolution of complaints that are made by, or on behalf of, NF residents, and persons residing in CBRA settings, including ACLFs and Adult Care Homes. The Tennessee LTC Ombudsman Program is administered by the TCAD.

(135) Long-Term Services and Supports (LTSS) Enrollee or Participant. An individual who is participating in a TennCare LTSS Program.

(136) Long-Term Services and Supports (LTSS) Program. One of the programs offering LTSS to individuals enrolled in TennCare. LTSS Programs include institutional programs (NFs and ICFs/IID), HCBS offered through CHOICES or through a Section 1915(c) HCBS Waiver Program, and the PACE Program.

(137) Managed Care Organization (MCO). See "Managed Care Organization" in Rule 1200-13-13-.01.

(138) Managed Care System. A system under which the MCOs are responsible for arranging for services and paying claims for delivery of these services to Members enrolled in their plans.

(139) Medicaid. As used in this Chapter, the term Medicaid refers to:

(a) The Social Security Act Title XIX program administered by the Single State Agency through CMS and any of the waivers granted to the State of Tennessee; or,

(b) Specific categories of eligibility established by Title XIX. The eligibility category in which a person qualifies for TennCare may determine the benefits the person is eligible to receive, and his cost sharing obligations.

(140) Medicaid Diversion Group Part B. The component of Tennessee's Katie Beckett Program which offers only a capped package of wraparound services and supports including premium assistance on a sliding fee scale to a broader group of children with disabilities, including those "at risk" of institutionalization. Medicaid Diversion Group Part B is an innovative, new approach that will help divert children from becoming Medicaid eligible by helping their families purchase private insurance and providing wraparound services and supports to meet the child's needs. Medicaid Diversion Group Part B will consist of children who are under age 18 who (1) have medical needs that are likely to last at least twelve months or result in death and result in severe functional limitations based on medical eligibility criteria developed specifically for children; (2) qualify for care in a medical institution or be "at-risk" of institutional placement; (3) are not Medicaid eligible or receiving other long-term services and supports in another TennCare Medicaid program; and (4) the child is not eligible for Katie Beckett Group Part A or is not enrolled in Katie Beckett Group Part A due to program target enrollment.

(141) Medicaid Only Payer Date (MOPD). The date a NF certifies that Medicaid reimbursement for NF services will begin because the Applicant has been admitted to the facility and all other primary sources of reimbursement (including Medicare and private pay) have been exhausted. (This does not preclude the Applicant's responsibility for payment of Patient Liability as described in these rules.) The MOPD must be known (and not projected) as it will result in the determination of eligibility for Medicaid reimbursement of NF services and in many cases, eligibility for Medicaid, as well as a capitation payment and payments for Medicaid services received, including but not limited to LTSS. The PAE may be submitted without an MOPD date, in which case the MOPD shall be submitted by the facility when it is known. Enrollment into CHOICES Group 1 and eligibility for reimbursement of NF services shall be permitted only upon submission of a MOPD. The effective date of CHOICES enrollment and Medicaid reimbursement of NF services shall not be earlier than the MOPD.

(142) Medicare Savings Program. The mechanisms by which low-income Medicare beneficiaries can get assistance from Medicaid in paying for their Medicare premiums, deductibles, and/or coinsurance. These programs include the Qualified Medicare Beneficiary (QMB) program, the Specified Low Income Medicare Beneficiary (SLMB) program, and the Qualified Individual (QI) program.

(143) Member. An individual who is enrolled in CHOICES, ECF CHOICES, or Katie Beckett Group Part A.

(144) Mental Illness (MI). For the purposes of compliance with federal PASRR regulations, an individual who meets the following requirements on diagnosis, level of impairment and duration of illness:

(a) The individual has a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, which is a schizophrenic, mood, paranoid, panic or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability; but is not a primary diagnosis of dementia, including Alzheimer's disease or a related disorder, or a non-primary diagnosis of dementia unless the primary diagnosis is a major mental disorder;

(b) The level of impairment must result in functional limitations in major life activities within the past three (3) to six (6) months that would be appropriate for the individual's developmental stage; or

(c) The treatment history of the individual has at least one of the following: a psychiatric treatment more intensive than outpatient care more than once in the past two (2) years, or within the last two (2) years, due to a mental disorder, the individual has experienced an episode of significant disruption to the normal living situation, for which supportive services were required to maintain functioning at home, or in a residential treatment environment, or which resulted in intervention by housing or law enforcement officials.

(145) Mental Retardation (MR) and Related Conditions. For the purposes of compliance with federal PASRR regulations, an individual is considered to have MR if he has a level of retardation (mild, moderate, severe and profound) as described in the American Association on Mental Deficiency's Manual on Classification in Mental Retardation (1983).

(a) MR refers to significantly subaverage general intellectual functioning, indicated by an IQ test score of 70 or below, existing concurrently with deficits in adaptive behavior and manifested during the developmental period (i.e., prior to age eighteen).

(b) The provisions of this Paragraph also apply to persons with "related conditions", as defined by 42 C.F.R. § 435.1010, which states: "Persons with related conditions" means individuals who have a severe, chronic disability that meets all of the following conditions:

1. It is attributable to:

(i) Cerebral palsy or epilepsy, or

(ii) Any other condition, other than MI, found to be closely related to MR because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with MR, and requires treatment or services similar to those required for these persons.

2. It is manifested before the person reaches age twenty-two (22).

3. It is likely to continue indefinitely.

4. It results in substantial functional limitations in three or more of the following areas of major life activity:

(i) Self-care;

(ii) Understanding and use of language;

(iii) Learning;

(iv) Mobility;

(v) Self-direction; and

(vi) Capacity for independent living.

(146) Minor Home Modifications. For purposes of CHOICES, ECF CHOICES, and for purposes of the Katie Beckett Program and limited to children enrolled in Katie Beckett Group Part A or Medicaid Diversion Group Part B:

(a) Included are the following:

1. The provision and installation of certain home mobility aids, including but not limited to:

(i) Wheelchair ramps and modifications directly related to and specifically required for the construction or installation of the ramps;

(ii) Hand rails for interior or exterior stairs or steps; or

(iii) Grab bars and other devices.

2. Minor physical adaptations to the interior of a Member's place of residence that are necessary to ensure his health, welfare and safety, or which increase his mobility and accessibility within the residence, including but not limited to:

(i) Widening of doorways; or

(ii) Modification of bathroom facilities.

(b) Excluded are the following:

1. Installation of stairway lifts or elevators;

2. Adaptations that are considered to be general maintenance of the residence;

3. Adaptations that are considered improvements to the residence;

4. Adaptations that are of general utility and not of direct medical or remedial benefit to the individual, including but not limited to:

(i) Installation, repair, replacement or roof, ceiling, walls, or carpet or other flooring;

(ii) Installation, repair, or replacement of heating or cooling units or systems;

(iii) Installation or purchase of air or water purifiers or humidifiers;

(iv) Installation or repair of driveways, sidewalks, fences, decks, and patios; and

(v) Adaptations that add to the total square footage of the home are excluded from this benefit.

(c) All services shall be provided in accordance with applicable State or local building codes.

(d) Regardless of payer, Minor Home Modifications shall not be provided to Members living in an ACLF, Adult Care Home, Residential Home for the Aged or other group residential setting. Minor Home Modifications shall not be provided to Members receiving Short-Term NF services, except as provided in Rule 1200-13-01-.05 to facilitate transition to the community.

(e) Minor home modifications are subject to a limit of $6, 000 per project, $10, 000 per calendar year, and $20, 000 per lifetime.

(147) Multiple Complex Health Conditions. For purposes of reserve capacity in ECF CHOICES, a limited number of individuals who have multiple complex chronic or acquired health conditions that present significant barriers or challenges to employment and community integration, and who are in urgent need of supports in order to maintain the current living arrangement and delay or prevent the need for more expensive services, and for which enrollment into ECF CHOICES is the most appropriate way to provide needed supports, as determined through an Interagency Committee review process, including both TennCare and DIDD. Multiple Complex Health Conditions shall be applicable only to individuals of working age.

(148) Natural Supports. For purposes of CHOICES:

(a) Unpaid support and assistance critical to ensuring the health, safety, welfare and quality of life of a Member residing in the community delivered by family members, friends, neighbors, and other entities including clubs, churches and community organizations.

(b) May be supplemented, but not supplanted by paid HCBS in order to help sustain the Natural Supports over time, and to help insure the delivery of cost effective community based care.

(149) Network Provider. See "Contract Provider."

(150) Non-Contract Provider. A provider who does not have a contract with an Enrollee's MCO. Also called "Out-of-Network Provider."

(151) Notice. When used in rules and regulations pertaining to NFs, information that must be provided by the facility to "residents" or "Applicants, " and shall also include notification to the person identified in a PAE application as the resident's or Applicant's Designated Correspondent and any other individual who is authorized by law to act on the resident's or Applicant's behalf or who is in fact acting on the resident's or Applicant's behalf in dealing with the NF.

(152) Notice of Disposition or Change. A notice issued by DHS of an individual's financial eligibility for TennCare, including the effective date for which a person may qualify for TennCare reimbursement of LTSS, subject to Level of Care and other applicable eligibility/enrollment criteria as defined in this Chapter.

(153) Nurse Care Manager. For purposes of the Katie Beckett Group Part A, a person who is employed by an MCO to perform responsibilities related to continuous engagement and management of:

(a) Assessing a child's strengths, physical and behavioral health and long-term services and supports needs, goals and challenges;

(b) Identifying the services and supports (including unpaid supports voluntarily provided by family members and other caregivers, and paid services provided by private insurance, the MCO, and other payor sources) that will be provided to the child to meet the child's physical and behavioral health and long-term services and supports needs, and support the child in achieving his or her individualized goals;

(c) Working closely with providers in implementing the plan of care. Long-term services and supports identified through nurse care management and provided by the MCO shall build upon and not supplant a member's existing support system, including but not limited to informal supports provided by family and other caregivers, service that may be available at no cost to the member through other entities, and services that are reimbursable through other public or private funding sources, such as Medicare or private insurance;

(d) Developing and maintaining for each member, through a person and family centered planning process, an individualized, plan of care. The child should be involved in helping define his or her individualized goals and develop the plan of care the maximum extent possible and appropriate. This planning process, and the resulting person and family centered plan of care shall:

1) ensure the delivery of services in a manner that reflects the family's strengths, needs, preferences and choices;

2) assists the child in achieving personally defined outcomes in the most integrated community setting, which shall include planning and preparation for the child's transition to employment and community living with as much independence as possible upon becoming an adult; and

3) help to engage, strengthen, support and build the capacity and confidence of the family in order to ensure the child's safety, well-being and permanency;

(e) Ensuring timely access to and provision, coordination and monitoring of covered physical and behavioral health services and wraparound HCBS; and

(f) Collaboration between providers and payors of the member's physical and behavioral health services and wraparound HCBS, including physicians, other physical and behavioral health care providers, HCBS providers, TennCare, DIDD, the local education authority, Vocational Rehabilitation, and the MCO to facilitate seamless access to care and maximize health and quality of life outcomes, and to plan and prepare for the child's transition to employment and community living with as much independence as possible upon becoming an adult.

(154) Nursing Facility (NF). A Medicaid-certified NF.

(155) Nursing Facility (NF) Eligible. An individual determined by DHS to qualify for TennCare reimbursement of NF services and determined by the Bureau to meet NF Level of Care.

(156) One-Time CHOICES HCBS. Certain CHOICES HCBS which occur as a distinct event or which may be episodic in nature (occurring at irregular intervals or on an as needed basis for a limited duration of time), including In-Home Respite Care, Inpatient Respite, Assistive Technology, Minor Modifications, and Pest Control.

(157) One-Time ECF CHOICES HCBS. Specified ECF CHOICES HCBS other than employment services and supports which occur as a distinct event or which may be episodic in nature (occurring at less frequent irregular intervals or on an as needed basis for a limited duration of time). One-time ECF CHOICES HCBS include: Decision Making Supports, Minor Home Modifications, Individual Education and Training Services, Specialized Consultation and Training, Adult Dental Services, Community Support Development, Organization and Navigation, Family Caregiver Education and Training, Assistive Technology, Adaptive Equipment and Supplies, Peer-to-Peer Support and Navigation for Person Centered Planning, Self-Direction, Integrated Employment/Self Employment, and Independent Community Living, Respite, Family-to-Family Support, and Health Insurance Counseling/Forms Assistance.

(158) Ongoing CHOICES HCBS. Certain CHOICES HCBS which are delivered on a regular and ongoing basis, generally one or more times each week, or (in the case of Community-Based Residential Alternatives and PERS) on a continuous basis, including Community-Based Residential Alternatives, Personal Care Visits, Attendant Care, Home-Delivered Meals, Personal Emergency Response Systems, and Adult Day Care.

(159) Ongoing ECF CHOICES HCBS. Specified ECF CHOICES HCBS which are delivered on a regular and ongoing basis, generally one or more times each week, or in the case of community-based residential alternatives on a continuous basis, or which may be one component of a continuum of services intended to achieve employment. Ongoing ECF CHOICES HCBS include: Supportive Home Care, Family Caregiver Stipend in lieu of Supportive Home Care, Independent Living Skills Training, Community Integration Support Services, Personal Assistance, Community Transportation, Community Living Supports (CLS), Community Living Supports Family Model (CLS-FM), Exploration, Discovery, Benefits Counseling, Situational Observation and Assessment, Job Development or Self-Employment Plan, Job Development or Self-Employment Start Up, Job Coaching (including Competitive, Integrated Employment and Self-Employment), Supported Employment - Small Group, Co-worker Supports, Career Advancement, and Integrated Employment Path Services (Time Limited Pre-Vocational Training).

(160) Out-of-Network Provider. See "Non-Contract Provider."

(161) PACE Carryover Group.

(a) Individuals who were enrolled in PACE as of June 30, 2012, but who, upon redetermination, no longer qualify for enrollment due solely to the State's modification of its NF LOC criteria.

(b) Members eligible for TennCare in the PACE Carryover Group may continue to qualify in this group after June 30, 2012, so long as they:

1. Continue to meet NF financial eligibility;

2. Continue to meet the NF LOC criteria in place as of June 30, 2012;

3. Meet all other eligibility requirements for PACE in the Medicaid State Plan; and

4. Remain continuously enrolled in PACE.

(162) PAE Effective Date. The beginning date of LOC eligibility for TennCare-reimbursed LTSS for which the PAE has been approved by the Bureau and which, for purposes of care in a NF, cannot precede completion of the PASRR process.

(163) Patient Liability. The amount determined by DHS that a TennCare Eligible is required to pay for covered services provided by a NF, an ICF/IID, an HCBS waiver program, or CHOICES.

(164) Peer-to-Peer Support and Navigation for Person-Centered Planning, Self-Direction, Integrated Employment/Self-Employment and Independent Community Living. For purposes of ECF CHOICES only and limited to members enrolled in ECF CHOICES Group 5 (Essential Supports for Employment and Independent Living) or Group 6 (Comprehensive Supports for Employment and Community Living):

(a) These services assist an individual and his/her family member(s) or conservator in one or more of the following areas:

1 Directing the person-centered planning process;

2. Understanding and considering self-direction;

3. Understanding and considering individualized integrated employment/self-employment; or

4. Understanding and considering independent community living options.

(b) The service involves addressing questions and concerns related to such options. Services are provided by a peer who has successfully directed his or her person-centered planning process, self-directed his or her own services, successfully obtained individualized integrated employment or self-employment and/or utilized independent living options.

(c) Peer-to-Peer Support and Navigation for Person-Centered Planning, Self-Direction, Integrated Employment/Self-Employment and Independent Community Living services are provided by individuals with intellectual or developmental disabilities (with paid supports if needed) who have successfully directed their person-centered planning processes, and/or self-directed their own services, and/or successfully utilized independent living options. Individuals with intellectual or developmental disabilities qualified to provide these services will have also completed training in best practices for offering peer to peer supports in the areas covered by this service.

(d) Peer-to-Peer Support and Navigation for Person-Centered Planning, Self-Direction, Integrated Employment/Self-Employment and Independent Community Living services are focused on mentoring and training others based upon their personal experience and success in one or more areas this service is focused on. A qualified service provider understands, empathizes with and can support three important areas important for enhancing self-esteem:

1. The human need for connections;

2. Overcoming the disabling power of learned helplessness, low expectations and the stigma of labels; and

3. Supporting self-advocacy, self-determination and informed choice in decision making.

(e) The Peer-to-Peer Support and Navigation for Person-Centered Planning, Self-Direction, Integrated Employment/Self-Employment and Independent Community Living service provider offers:

1. One-on-one training and information to encourage the person to lead their person-centered planning process, pursue self-direction, seek integrated employment/self-employment and/or independent community living options;

2. Education on informed decision making, risk taking, and natural consequences;

3. Education on self-direction, including recruiting, hiring and supervising staff;

4. Planning support regarding integrated employment;

5. Planning support regarding independent community living opportunities, including selection of living arrangements and housemates; and

6. Assistance with identifying potential opportunities for community participation, the development of valued social relationships, and expanding unpaid supports to address individual needs in addition to paid services.

(f) These services are intended to support an individual in knowledge and skill acquisition and should not be provided on an ongoing basis, nor should these services be provided for companionship purposes. Reimbursement shall be limited to $1, 500 per person per lifetime.

(165) Person-Centered Support Plan (PCSP). As it pertains to CHOICES, ECF CHOICES, and Katie Beckett Group Part A the PCSP is a written plan developed by the Support Coordinator, Care Coordinator, or Nurse Care Manager in accordance with person-centered planning requirements set forth in federal regulation, and in TennCare policies and protocols, using a person-centered planning process that accurately documents the member's strengths, needs, goals, lifestyle preferences and other preferences and outlines the services and supports that will be provided to the member to help them achieve their preferred lifestyle and goals, and to meet their identified unmet needs (after considering the availability and role of unpaid supports provided by family members and other natural supports) through paid services provided by the member's MCO and other payor sources. The person-centered planning process is directed by the member with long-term support needs, and may include a representative whom the member has freely chosen to assist the member with decision-making, and others chosen by the member to contribute to the process. If the member is a child, has a legal guardian, or conservator, the member shall lead the planning process to the maximum extent possible, and the parent, legal guardian, or conservator shall have a participatory role as needed and defined by the individual, except as explicitly defined under State law and the order of guardianship or conservatorship. Any decisions made on the member's behalf should be made using principles of substituted judgment and supported decision making. This planning process, and the resulting PCSP, will assist the member in achieving a personally defined lifestyle and outcomes in the most integrated community setting, ensure delivery of services in a manner that reflects personal preferences and choices, and contribute to the assurance of health, welfare, and personal growth. Services in CHOICES, ECF CHOICES, and Katie Beckett Group Part A shall be authorized, provided, and reimbursed only as specified in the PCSP. See also Plan of Care below.

(166) Personal Assistance. For purposes of ECF CHOICES only and limited to adults age 21 or older enrolled in ECF CHOICES Group 5 (Essential Supports for Employment and Independent Living) or Group 6 (Comprehensive Supports for Employment and Community Living):

(a) A range of services and supports designed to assist an individual with a disability to perform activities and instrumental activities of daily living at the person's own home, on the job or in the community that the individual would typically do for themselves if he/she did not have a disability. Personal Assistance services may be provided outside of the person's home as long as the outcomes are consistent with the supports defined in the person-centered support plan with the goal of ensuring full participation and inclusion.

(b) Personal Assistance services may be used to:

1. Support the person at home in getting ready for work and/or community participation;

2. Support the person in getting to work and/or community participation opportunities; and

3. Support the person in the workplace and/or in the broader community.

(c) The only exception is if Supported Employment Services or Community Integration Support Services are being provided, in which case the provider of Supported Employment and/or Community Integration Support Services shall be responsible for personal assistance needs during the hours that Supported Employment services are provided as long as the Personal Assistance Services do not comprise the entirety of the Supported Employment or Community Integration Support Service. If a person only needs personal assistance to participate in employment or community opportunities, then this service should be authorized rather than Supported Employment or Community Integration Support Services.

(d) Personal Assistance services that are covered also include the following:

1. Support, supervision and engaging participation with eating, toileting, personal hygiene and grooming, and other activities of daily living as appropriate and needed to sustain community living, except when provided as a component of another covered service the person is receiving at that time; and

2. Direction and training to individuals in the person's social network or to his/her coworkers who choose to learn how to provide some of the Personal Assistance services.

(e) In ECF CHOICES Group 6 (Comprehensive Supports for Employment and Community Living), Personal Assistance services shall be limited to 215 hours per month. An MCO may authorize services in excess of the benefit limit as a cost-effective alternative to institutional placement or other medically necessary covered benefits.

(167) Personal Care Visits. For purposes of CHOICES:

(a) Visits to a Member who, due to age and/or Physical Disabilities, needs assistance that can be provided through intermittent visits of limited duration not to exceed four (4) hours per visit and two (2) visits per day at intervals of no less than four (4) hours between visits to provide hands-on assistance and related tasks as specified below.

(b) Personal Care Visits may include assistance with ADLs such as bathing, dressing and personal hygiene, eating, toileting, transfers and ambulation.

(c) For Members who require hands-on assistance with ADLs, Personal Care Visits may also include the following homemaker services that are essential, although secondary, to the hands-on assistance with ADLs needed by the Member in order to continue living at home because there is no household member, relative, caregiver, or volunteer to meet the specified need, such as:

1. Picking up the Member's medications or shopping for the Member's groceries.

2. Preparing the Member's meals and/or educating caregivers about the preparation of nutritious meals for the Member.

3. Household tasks such as sweeping, mopping, and dusting in areas of the home used by the Member, changing the Member's linens, making the Member's bed, washing the Member's dishes, and doing the Member's personal laundry, ironing and mending.

(d) Personal Care Visits shall not be provided for Members who do not require hands-on assistance with ADLs.

(e) Personal Care Visits shall be primarily provided in the Member's place of residence, except as permitted within the scope of service (e.g., picking up medications or shopping for groceries), when accompanying or transporting the Member into the community pursuant to rule 1200-13-01-.05(8)(n), or under exceptional circumstances as authorized by an MCO in the POC to accommodate the needs of the Member.

(f) A single Contract Provider staff person or Consumer-Directed Worker may provide Personal Care Visits to multiple CHOICES Members in the same home and during the same hours, as long as he can provide the services safely and appropriately to each Member. Such arrangements shall be documented in each Member's plan of care. In such instances, the total units of service provided by the staff person shall be allocated among the CHOICES Members, based on the percentage of total service units required by each Member on average. The Provider shall bill the MCO only once for each of the service units provided, and shall not bill an MCO or multiple MCOs separately to provide services to multiple Members at the same time.

(g) Regardless of payer, Personal Care Visits shall not be provided to Members living in an ACLF, Adult Care Home, Residential Home for the Aged or other group residential setting, or receiving CBRA (including Companion Care) or Short-Term NF services, or while a Member is receiving Adult Day Care services.

(h) Personal care visits shall not include:

1. Companion or sitter services, including safety monitoring and supervision.

2. Care or assistance including meal preparation or household tasks for other residents of the same household.

3. Yard work.

4. Care of non-service related pets and animals.

(168) Personal Emergency Response System (PERS). For purposes of CHOICES:

(a) An electronic device that enables certain Members at high risk of institutionalization to summon help in an emergency. The Member may also wear a portable "help" button to allow for mobility. The system is programmed to signal a response center once the "help" button is activated. The response center is staffed by trained professionals who assess the nature of the emergency, and obtain assistance for the individual, as needed. PERS services are limited to those Members who have demonstrated mental and physical capacity to utilize such system effectively and who live alone or who are alone with no caregiver for extended periods of time, such that the Member's safety would be compromised without access to a PERS.

(b) Regardless of payer, PERS shall not be provided to Members living in an ACLF, Adult Care Home, Residential Home for the Aged or other group residential setting, or receiving CBRA (including Companion Care) or Short-Term NF services, provided however, that an MCO may authorize PERS for a CHOICES member receiving Companion Care, Community Living Supports, or Community Living Supports-Family Model services when such service provides less than 24-hour staff support and PERS is medically necessary in order to help sustain or increase the member's independence in the home, reduce risk of safety concerns, and delay or prevent nursing home placement.

(169) Personal Needs Allowance (PNA). A reasonable amount of money that is deducted by DHS from the individual's funds pursuant to federal and State law and the Medicaid State Plan in the application of post-eligibility provisions and the calculation of Patient Liability for LTSS. The PNA is set aside for clothing and other personal needs of the individual while in the institution (Institutional PNA), and to also pay room, board and other living expenses in the community (Community PNA).

(170) Pest Control.

(a) The one-time or intermittent use of sprays, poisons and traps, as appropriate, in the Member's residence (excluding NFs or ACLFs) to regulate or eliminate the intrusion of cockroaches, wasps, mice, rats and other species of household pests into the household environment thereby removing an environmental issue that could be detrimental to a Member's health and physical well-being.

(b) Regardless of payer, shall not be provided to Members living in an ACLF, Adult Care Home, Residential Home for the Aged or other group residential setting, or receiving Short-Term NF services.

(c) A treatment visit for Pest Control is a visit by the Pest Control provider to the Member's residence during which the Pest Control treatment is applied.

(d) Shall not be provided solely as a preventive measure. There must be documentation of a need for this service either through Care Coordinator direct observation or determination through a needs assessment that a household pest is causing or is expected to cause more harm than is reasonable to accept.

(e) Shall not include treatment for termites, bed bug infestations or any pest infestation that cannot be addressed through intermittent visits as provided through the current benefit and reimbursement structure.

(171) Pharmacy Benefits Manager (PBM). See "Pharmacy Benefits Manager" in Rule 1200-13-13-.01.

(172) Physical Disabilities.

(a) One or more medically diagnosed chronic, physical impairments, either congenital or acquired, that limit independent, purposeful physical movement of the body or of one or more extremities, as evidenced by substantial functional limitations in one or more ADLs that require such movement-primarily mobility or transfer-and that are primarily attributable to the physical impairments and not to cognitive impairments or mental health conditions. For purposes of eligibility for enrollment in CHOICES Group 2, includes any adult age 21 or older who meets level of care criteria for Medicaid Level 1 reimbursement of care in a nursing facility, CHOICES HCBS and PACE, including requirements set forth in TennCare Rule 1200-13-01-.10(4)(b) 2.(ii) and, based upon review of evidence by TennCare, will be institutionalized but for the availability of these services.

(b) An individual with cognitive impairments or mental health conditions who also has one or more Physical Disabilities as defined above may qualify as "Physically Disabled, " and may be enrolled into CHOICES Group 2 or CHOICES Group 3 so long as such individual can be safely served in the community and at a cost that does not exceed the individual's Cost Neutrality Cap or Expenditure Cap, as applicable. This includes consideration of whether or not the CHOICES Group 2 or CHOICES Group 3 benefit package, as applicable, adequately addresses any specialized service needs the applicant may have pertaining to the cognitive impairment or mental health condition, as applicable.

(173) Physically Disabled. For purposes of enrollment into CHOICES Group 2 or CHOICES Group 3, an adult aged twenty-one (21) or older who has one or more Physical Disabilities.

(174) Physician. A doctor of medicine or osteopathy who has received a degree from an accredited medical school and who is licensed to practice his profession in Tennessee.

(175) Plain Language. Any notice or explanation written at a level that does not exceed the sixth grade reading level as measured by the Flesch Index, Fog Index, or Flesch-Kincaid Index.

(176) Plan of Care. A written document that is developed in a manner consistent with 42 CFR § 441.301(c)(1) through a person-centered planning process based on an individualized assessment of an Enrollee's needs that specifies the types and frequency of LTSS that the Enrollee receives. As it pertains to Part A of the Katie Beckett Program, the plan of care is a written document developed by the Nurse Care Manager through a person- and family-centered planning process that assesses the child's strengths, needs, goals and challenges; and outlines the services and supports (including unpaid supports voluntarily provided by family members and other caregivers, and paid services provided by private insurance, the MCO, and other payor sources) that will be provided to the child to meet the child's physical and behavioral health and long-term services and supports needs and support the child in achieving his or her individualized goals. As it pertains to Medicaid Diversion Group Part B, the plan of care is a written document developed by the DIDD Katie Beckett Case Manager through a person- and family-centered planning process that assesses the child's strengths, needs, goals and challenges; and outlines the home and community based services and supports that will be provided to the child to meet the child's needs and support the child in achieving his or her individualized goals. The child should be involved in helping to define his or her individualized goals and develop the plan of care to the maximum extent possible and appropriate. This planning process, and the resulting person-centered plan of care shall:

1) ensure the delivery of services in a manner that reflects the child and family's strengths, needs, preferences and choices;

2) assist the child in achieving personally defined outcomes in the most integrated community setting, which shall include planning and preparation for the child's transition to employment and community living with as much independence as possible upon becoming an adult;, and

3) help to engage, strengthen, support, and build the capacity and confidence of the family in order to ensure the child's safety, well-being and permanency. Services in the Katie Beckett Program shall be authorized, provided, and reimbursed only as specified in the plan of care. For purposes of Part A of the Katie Beckett Program "plan of care" shall be used interchangeably with "person-centered support plan" or "PCSP." For purposes of Medicaid Diversion Group Part B, "plan of care" shall be used interchangeably with "individual support plan" or "ISP."

(177) Potential Applicant. Individuals for whom TennCare or its designee shall perform referral and intake functions as specified in these rules. A Potential Applicant is entitled to a determination regarding his or her eligibility to enroll in the ECF CHOICES program and, if the application is denied, to due process, including notice and the right to request a fair hearing only when the Potential Applicant is determined to meet criteria for an available reserve capacity slot or meets prioritization criteria for an available program slot for which enrollment is currently open and will be enrolled into the program if all applicable eligibility and enrollment criteria are met.

(178) PreAdmission Evaluation (PAE). A process of assessment by the Bureau used to determine an individual's medical (or LOC) eligibility for TennCare-reimbursed care in a NF or ICF/IID, and in the case of NF services, the appropriate level of reimbursement for such care, as well as eligibility for HCBS as an alternative to institutional care, or in the case of persons At Risk for Institutionalization, in order to delay or prevent NF placement. For purposes of CHOICES, the PAE application shall be used for the purposes of determining LOC and for persons enrolled in CHOICES Group 2, calculating the Member's Individual Cost Neutrality Cap.

(179) PreAdmission Screening/Resident Review (PASRR). The process by which the State determines whether an individual who resides in or seeks admission to a Medicaid-certified NF has, or is suspected of having, MI or MR, and, if so, whether the individual requires specialized services and is appropriate for NF placement.

(a) Identification Screen (Level I). The initial screening conducted to determine which NF Applicants or residents have MI or MR and are subject to PASRR. Individuals with a supportable primary diagnosis of Alzheimer's disease or dementia will also be detected through the Identification Screen. NFs are responsible for ensuring that all Applicants receive a Level I identification screen prior to admission to the facility, and for submission of the Level I Identification Screen to the Bureau.

(b) PASRR Evaluation (Level II). The process whereby a determination is made about whether the individual identified in the Level I screen requires the level of services provided by a NF or another type of facility and, if so, whether the individual requires specialized services. These reviews shall be the responsibility of the DMH and/or DIDD, as applicable.

(180) Private Duty Nursing (PDN) Services. See "Private Duty Nursing Services" in Rule 1200-13-13-.01.

(181) Program of All-Inclusive Care for the Elderly (PACE). A program for dually eligible Enrollees in need of LTSS that is authorized under the Medicaid State Plan, Attachment 3.1-A, #26.

(182) Provider. See "Provider" in Rule 1200-13-13-.01. Provider does not include Consumer-Directed Workers (see Consumer-Directed Worker); nor does Provider include the FEA (see Fiscal Employer Agent).

(183) Qualified Assessor. A practicing professional who meets the qualifications established by TennCare to certify the accuracy of a level of care assessment as reflected in the PAE application. For the CHOICES program, Qualified Assessors shall include only the following: a licensed physician, nurse practitioner, physician assistant, registered or licensed nurse, licensed social worker, or an individual who has a bachelor's degree in social work, nursing, education or other human service (e.g., psychology or sociology) and is also prior approved by TennCare on a case-by-case basis. For the ECF CHOICES program, Qualified Assessors shall include the preceding individuals and shall also include individuals who meet the federal requirements for a Qualified Intellectual Disabilities Professional or Qualified Developmental Disabilities Professional or individuals who have five (5) or more years' experience as an independent support coordinator or case manager for service recipients in a 1915(c) HCBS Waiver and have completed Personal Outcome Measures Introduction and Assessment Workshop trainings as established by the Council on Quality and Leadership and are prior approved by TennCare on a case-by-case basis.

(184) Qualifying Income Trust (QIT). See "Qualified Income Trust" in DHS Rules Chapter 1240-03-03.

(185) Referral. An expression of interest in applying for the ECF CHOICES program.

(186) Related Conditions. See "Mental Retardation (MR) and Related Conditions."

(187) Representative.

(a) In general, for CHOICES and ECF CHOICES members, a person who is at least eighteen (18) years of age and is authorized by the member to participate in care or support planning and implementation and to speak and/or make decisions on the member's behalf, including but not limited to identification of needs, preference regarding services and service delivery settings, and communication and resolution of complaints and concerns, provided that any decision making authority not specifically delegated to a legal representative (e.g., a guardian or conservator) is retained by the member unless he or she chooses to allow a (non-legal) representative whom he or she has freely chosen to make such decisions.

(b) As it relates to consumer direction of eligible CHOICES or ECF CHOICES HCBS, a person who is authorized by the member to direct and manage the member's worker(s), and signs a representative agreement. The representative for consumer direction of eligible CHOICES or ECF CHOICES HCBS must also: be at least eighteen (18) years of age; have a personal relationship with the member and understand his/her support needs; know the member's daily schedule and routine, medical and functional status, medication regimen, likes and dislikes, and strengths and weaknesses; and be physically present in the member's residence on a regular basis or at least at a frequency necessary to supervise and evaluate workers.

(188) Representative Agreement. The agreement between a CHOICES or ECF CHOICES member or the parent or legal guardian of a child enrolled in Katie Beckett Group Part A or Medicaid Diversion Group Part B electing consumer direction of eligible CHOICES, ECF CHOICES, or Katie Beckett HCBS who has a representative direct and manage the consumer's worker(s) and the member's representative that specifies the roles and responsibilities of the member and the member's representative.

(189) Reserve Capacity. The State's right to maintain some capacity within an established Enrollment Target to enroll individuals into CHOICES HCBS under certain circumstances. These circumstances could include, but are not limited to:

(a) Discharge from a NF;

(b) Discharge from an acute care setting where institutional placement is otherwise imminent; or

(c) Other circumstances which the State may establish from time to time in accord with this Chapter.

(190) Reserve capacity slot. For the purposes of ECF CHOICES, the state's authority to reserve a finite number of program slots in a particular ECF CHOICES Group for persons in specified circumstances; such as an Aging Caregiver of a person with ID, Emergent Circumstances, and Multiple Complex Health Conditions as defined.

(191) Respite. For purposes of ECF CHOICES and Katie Beckett Group Part A and Medicaid Diversion Group Part B only:

(a) Respite shall mean services provided to a person supported when unpaid caregivers are absent or need relief from routine caregiving responsibilities.

(b) Respite shall be limited to 30 days of service per person per calendar year or to 216 hours per person per calendar year, depending on the needs and preferences of the individual as reflected in the PCSP.

1. A member shall choose to receive Respite as either a daily or hourly service. The 2 limits cannot be combined in a calendar year.

2. If a member chooses to receive Respite as a daily service, each 24 hour time period within which Respite is provided and reimbursed shall count as one day regardless of the number of hours of Respite services reimbursed during that 24 hour period.

3. Only hourly Respite shall be available through Consumer Direction. Daily Respite shall not be available through Consumer Direction.

(c) Respite services shall be provided in settings that meet the federal HCBS regulatory standards, which promote community involvement and inclusion and which allow individuals to sustain their lifestyle and routines when an unpaid caregiver is absent for a period of time.

(d) Respite shall be provided only for persons living with unpaid family caregivers, or (applicable only to ECF CHOICES) living independently (not in a CBRA setting), but having unpaid caregivers who routinely (i.e., daily or almost daily) have responsibilities to provide support to the member, and relief from such support is needed.

(192) Risk Agreement.

(a) An agreement signed by a Member who will receive CHOICES HCBS (or his Representative) that includes, at a minimum:

1. Identified risks to the Member of residing in the community and receiving HCBS;

2. The possible consequences of such risks, strategies to mitigate the identified risks; and

3. The Member's decision regarding his acceptance of risk.

(b) For Members electing to participate in CD, the Risk Agreement must include any additional risks associated with the Member's decision to act as the Employer of Record, or to have a Representative act as the Employer of Record on his behalf.

(193) Room and Board. Lodging, meals, and utilities that are the responsibility of the individual receiving HCBS in a CBRA facility. The kinds of items that are considered "Room and Board" and are therefore not reimbursable by TennCare include:

(a) Rent, or, if the individual owns his home, mortgage payments, depreciation, or mortgage interest;

(b) Property taxes;

(c) Insurance (title, mortgage, property and casualty);

(d) Building and/or grounds maintenance costs;

(e) Resident "raw" food costs including individual special dietary needs (the cost of preparing, serving, and cleaning up after meals is not included);

(f) Household supplies necessary for the room and board of the individual;

(g) Furnishings used by the resident;

(h) Utilities (electricity, water and sewer, gas);

(i) Resident telephone; or

(j) Resident cable or pay television.

(194) Safety Determination.

(a) A decision made by the Bureau in accordance with the process and requirements described in Rule 1200-13-01-.05(6) regarding whether:

1. An Applicant age 65 and older and is At Risk for Institutionalization as defined in Rule 1200-13-01-.02 or an Applicant age 21 and older who has a physical disability and is At Risk for Institutionalization as defined in Rule 1200-13-01-.02 would qualify to enroll in CHOICES Group 3 (including Interim CHOICES Group 3) or if there is sufficient evidence, as required and determined by the Bureau, to demonstrate that the necessary intervention and supervision needed by the Applicant cannot be safely provided within the array of services and supports that would be available if the Applicant was enrolled in CHOICES Group 3, including CHOICES HCBS up to the Expenditure Cap of $15, 000; non-CHOICES HCBS available through TennCare (e.g., home health); cost-effective alternative services (as applicable); services available through Medicare, private insurance or other funding sources; and natural supports provided by family members and other caregivers who are willing and able to provide such care, and which may impact the Applicant's NF LOC eligibility (see Rule 1200-13-01-.10(4)(b) 2.(i)(II) and 1200-13-01-.10(4)(b) 2.(ii)(II)).

2. An Applicant, age 21 and older who has an intellectual or developmental disability and is At Risk for Institutionalization as defined in Rule 1200-13-01-.02 would qualify to enroll in ECF CHOICES Group 5, or if there is sufficient evidence, as required and determined by the Bureau, to demonstrate that the necessary intervention and supervision needed by the Applicant cannot be safely provided within the array of services and supports that would be available if the Applicant was enrolled in ECF CHOICES Group 5, including ECF CHOICES HCBS up to the Expenditure Cap of $30, 000; one-time emergency assistance up to $6, 000; non-ECF CHOICES HCBS available through TennCare (e.g., home health); cost-effective alternative services (as applicable); services available through Medicare, private insurance or other funding sources; and natural supports provided by family members and other caregivers who are willing and able to provide such care, and which may impact the Applicant's NF LOC eligibility (see Rule 1200-13-01-.10(4)(b) 2.(ii)(III)).

(b) Such determination shall include review of information submitted to the Bureau as part of the Safety Determination request, including, but not limited to:

1. Ongoing skilled and/or rehabilitative interventions and treatment by licensed professional staff;

2. A pattern of recent falls resulting in injury or with significant potential for injury;

3. An established pattern of recent emergent hospital admissions or emergency department utilization for emergent conditions;

4. Recent nursing facility admissions, including precipitating factors and length of stay;

5. An established pattern of self-neglect that increases risk to personal health, safety and/or welfare requiring involvement by law enforcement or Adult Protective Services;

6. A determination by a community-based residential alternative provider that the Applicant's needs can no longer be safely met in a community setting;

7. The need for and availability of regular, reliable natural supports, including changes in the physical or behavioral health or functional status of family or unpaid caregivers; and

8. For Applicants who have an intellectual or developmental disability, the Applicant's adaptive and maladaptive behaviors as determined by the life skills assessment tool developed or selected by TennCare and the Maladaptive Behavior Index (MBI or problem behavior) portion of the Inventory for Client and Agency Planning (ICAP) Assessment to capture behaviors requiring extraordinary support to ensure the safety of the individual.

(195) Screening. One of three (3) components of the ECF CHOICES referral list management process which includes providing basic education about the program, including eligibility criteria and enrollment processes, and helps to gather basic information that can be used to determine if a Potential Applicant is likely to qualify for the program, and that allows the Potential Applicant to be prioritized for intake based on established prioritization and enrollment criteria.

(196) Self-Determination ID Waiver. Tennessee's Self Determination Waiver under Section 1915(c) of the Social Security Act.

(197) Self-Direction of Health Care Tasks.

(a) The decision by a CHOICES or ECF CHOICES Member participating in CD or the parent or legal guardian of a Katie Beckett Group Part A member to direct and supervise a paid Worker delivering Eligible CHOICES, ECF CHOICES, or Katie Beckett HCBS in the performance of Health Care Tasks that would otherwise be performed by a licensed nurse.

(b) The Self-Direction of Health Care Tasks is not a service, but rather health care-related duties and functions (such as administration of medications) that a CHOICES or ECF CHOICES Member participating in CD or the parent or other legal guardian of a child enrolled in Katie Beckett Group Part A of the Katie Beckett Program may elect to have performed by a Consumer-Directed Worker as part of the delivery of Eligible CHOICES, ECF CHOICES, or Katie Beckett HCBS he is authorized to receive.

(198) Service Agreement. The agreement between a CHOICES or ECF CHOICES member (or the member's representative), or the parent or legal guardian of a child enrolled in Katie Beckett Group Part A or Medicaid Diversion Group Part B electing consumer direction of HCBS and the member's consumer-directed worker that specifies the roles and responsibilities of the member (or the member's representative, parent or legal guardian) and the member's worker.

(199) Short-Term Nursing Facility (NF) Care. For purposes of CHOICES:

(a) The provision of NF care for up to ninety (90) days to a CHOICES Group 2 or CHOICES Group 3 Member who was receiving HCBS upon admission and who meets NF LOC and requires temporary placement in a NF-for example, due to the need for skilled or rehabilitative services upon hospital discharge or due to the temporary illness or absence of a primary caregiver-when such Member is reasonably expected to be discharged and to resume HCBS participation within no more than ninety (90) days.

(b) Such CHOICES Group 2 or CHOICES Group 3 Member must meet the NF LOC upon admission and in such case, while receiving Short-Term NF Care may continue enrollment in CHOICES Group 2 or CHOICES Group 3, pending discharge from the NF within no more than ninety (90) days or until such time it is determined that discharge within ninety (90) days from admission is not likely to occur, at which time the Member shall be transitioned to CHOICES Group 1, as appropriate.

(c) The Community PNA shall continue to apply during the provision of Short-Term NF care, up to the ninetieth (90th) day, in order to allow sufficient resources for the Member to maintain his community residence for transition back to the community.

(d) The PASRR process is required for CHOICES Group 2 and CHOICES Group 3 Members entering Short-Term NF Care.

(e) Persons receiving Short-Term NF Care are not eligible to receive any other HCBS, except as permitted in 1200-13-01-.05 to facilitate transition to the community.

(200) Single Point of Entry (SPOE). The agency charged with screening, intake, and facilitated enrollment processes for non-TennCare eligible individuals seeking enrollment into CHOICES.

(201) Situational Observation and Assessment. For purposes of ECF CHOICES only and limited to members age 14 or older:

(a) This is a time-limited service that involves observation and assessment of an individual's interpersonal skills, work habits and vocational skills through practical experiential, community integrated volunteer experiences and/or paid individualized, integrated work experiences that are uniquely arranged and specifically related to the interests, preferences and transferable skills of the job seeker as established through Discovery or a similar process. This service involves a comparison of the actual performance of the individual being assessed with core job competencies and duties required of a skilled worker in order to further determine the work competencies and skills needed by the individual to be successful in environments similar to where the Assessment is taking place. The individual shall be reimbursed at least the minimum wage and all applicable overtime for work performed, except as permitted pursuant to the Fair Labor Standards Act for unpaid internships.

(b) Situational Observation and Assessment shall be limited to no more than thirty (30) calendar days from the date of service initiation. Each job seeker may be authorized for up to four (4) such experiences within the thirty (30) calendar day period. A summary report, using a standard template prescribed by TennCare, is due within ten (10) days after the last date of service is concluded. Reimbursement is paid on an outcome basis for each individual experience, which is expected to involve an average of twelve (12) hours of service per individual experience. The Situational Observation and Assessment outcome payment is made after the written summary report is received and approved, and the provider submits documentation detailing each date of service, the activities performed that day, and the duration of each activity.

(c) The learning from this service described in the summary report is to be used to help inform the job development plan or self-employment plan.

(d) After an individual has received the service for the first time, re-authorization may occur a maximum of once every three years (with a minimum of three 365-day intervals between services), and only if the person, at the time of re-authorization, is not already engaged in individualized integrated employment or self-employment, or other services to obtain such employment, and the person has a goal to obtain individualized integrated employment or self-employment within twelve (12) months.

(202) Skilled Nursing Facility (SNF). A Medicare-certified SNF.

(203) Skilled Nursing Service. A Physician-ordered nursing service the complexity of which is such that it can only be safely and effectively provided directly by a registered nurse or licensed practical nurse.

(204) Skilled Rehabilitative Service. A Physician-ordered rehabilitative service the complexity of which is such that it can only be safely and effectively provided by qualified health care personnel (e.g., registered physical therapist, licensed physical therapist assistant, registered occupational therapist, certified occupational therapy assistance, licensed respiratory therapist, licensed respiratory therapist assistant).

(205) Specialized Consultation and Training. For purposes of ECF CHOICES only, and limited to adults age 21 or older enrolled in ECF CHOICES Group 5 (Essential Supports for Employment and Independent Living) or Group 6 (Comprehensive Supports for Employment and Community Living):

(a) Expertise, training and technical assistance in one or more specialty areas (behavior services, occupational therapy, physical therapy, speech language pathology, nutrition, orientation and mobility, or nurse education, training and delegation) to assist paid or natural or co-worker supports in supporting individuals who have long-term intervention needs, consistent with the person-centered support plan, therefore increasing the effectiveness of the specialized therapy or service. This service also is used to allow the specialists listed above to be an integral part of the person-centered planning team, as needed, to participate in team meetings and provide additional intensive consultation for individuals whose functional, medical or behavioral needs are determined to be complex. The consultation staff and the paid support staff are able to bill for their service time concurrently. Specialized Consultation and Training shall not include the ongoing provision of direct services. Activities that are covered include:

1. Observing the individual to determine and assess functional, medical or behavioral needs;

2. Assessing any current interventions for effectiveness;

3. Developing a written, easy-to-understand intervention plan, which may include recommendations for assistive technology/equipment, workplace and community integration site modifications; the intervention plan will clearly define the interventions, activities and expected timeline for completion of activities;

4. Identification of activities and outcomes to be carried out by paid and natural supports and co-workers;

5. Training of family caregivers or paid support personnel on how to implement the specific interventions/supports detailed in the intervention plan; in the case of nurse education, training and delegation, shall include specific training, assessment of competency, and delegation of skilled nursing tasks to be performed as permitted under state law;

6. Development of and training on how to observe, record data and monitor implementation of therapeutic interventions/support strategies;

7. Monitoring the individual, family caregivers and/or the supports personnel during the implementation of the plan;

8. Reviewing documentation and evaluating the activities conducted by relevant persons as detailed in the intervention plan with revision of that plan as needed to assure progress toward achievement of outcomes or revision of the plan as needed;

9. Participating in team meetings; and/or,

10. Tele-Consulting, as permitted under state law, through the use of two-way, real time interactive audio and video between places of greater and lesser clinical expertise to provide clinical consultation services when distance separates the clinical expert from the individual.

(b) Specialized Consultation Services are provided by a certified, licensed, and/or registered professional or qualified assistive technology professional appropriate to carry out the relevant therapeutic interventions for purposes of teaching and training, and not for the ongoing provision of direct services.

(c) Specialized Consultation Services are limited to $5, 000 per person per calendar year, except for adults in ECF CHOICES Group 6 (Comprehensive Supports for Employment and Community Living) determined by TennCare to have exceptional medical and/or behavioral support needs.

(d) Only for adults age 21 or older in ECF CHOICES Group 6 (Comprehensive Supports for Employment and Community Living) determined by TennCare to have exceptional medical and/or behavioral support needs, Specialized Consultation Services shall be limited to $10, 000 per person per calendar year.

(e) An MCO may authorize services in excess of the benefit limit as a cost-effective alternative to institutional placement or other medically necessary covered benefits.

(206) Specialized Services for Individuals with MI.

(a) The implementation of an individualized POC developed under and supervised by a Physician, provided by a Physician and other qualified mental health professionals that accomplishes the following;

1. Prescribes specific therapies and activities for the treatment of individuals who are experiencing an acute episode of severe MI, which necessitates continuous supervision by trained mental health personnel; and

2. Is directed toward diagnosing and reducing the individual's behavioral symptoms that necessitated institutionalization, improving his level of independent functioning, and achieving a functioning level that permits reduction in the intensity of mental health services to below the level of specialized services at the earliest possible convenience.

(b) Services to maintain generally independent individuals who are able to function with little supervision or in the absence of a continuous specialized services program are not included in this definition.

(207) Specialized Services for Individuals with MR and Related Conditions.

(a) The implementation of an individualized POC specifying a continuous program for each individual, which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services, and related services that is directed towards the acquisition of the behaviors necessary for the individual to function with as much self-determination and independence as possible; and the prevention or deceleration of regression or loss of current optimal functional status.

(b) Services to maintain generally independent individuals who are able to function with little supervision or in the absence of a continuous specialized services program are not included.

(208) Statewide ID Waiver. Tennessee's HCBS Waiver for the Mentally Retarded and Developmentally Disabled under Section 1915(c) of the Social Security Act.

(209) Substantial Functional Limitation. For purposes of Medical (Level of Care) Eligibility for the Katie Beckett Program only, a child's inability to perform specified functions at the level expected by the child's age or to perform activities of daily living (ADLs) as defined in this Rule without extensive, hands-on assistance significantly beyond the age at which similar aged peers typically require such assistance. This assistance must be needed by the child to complete the task or function at all, rather than to complete the task better, more quickly, or to make the task easier.

(a) In order for a limitation to be considered a substantial functional limitation, it must meet all of the following:

1. Be the direct result of the child's disability; and

2. Be exhibited most of the time; and

3. Result in the child needing extensive, direct, hands-on adult intervention and assistance beyond the level of intervention similar aged peers typically require in order to avoid institutionalization.

(b) In addition, the assistance the child requires to perform the function must meet all of the following:

1. Be required consistently; and

2. Be required for at least the next 12 months; and

3. Be required to complete the function across all settings, including home, school and community.

(c) Subject to (d) below, a child has a substantial functional limitation in an activity of daily living category (e.g., Bathing, Grooming, etc.) if the child exhibits at least one of the specific substantial functional limitations listed under the category for the child's particular age group. Not all activity of daily living categories apply to every age group due to developmental milestone variations of typically developing children.

(d) For purposes of Medical (Level of Care) Eligibility for Katie Beckett (including Tier 1 and Tier 2 Institutional LOC and At-Risk LOC), Bathing, Grooming, Dressing, Toileting, and Eating shall be combined into a single ADL category called "Self-Care." If a child exhibits deficits in multiple of these self-care activities of daily living, this shall still be counted as one substantial functional limitation (in self-care).

(210) Supported Employment-Small Group Supports. For purposes of ECF CHOICES only and limited to members age 16 or older:

(a) This service provides employment services and training activities to support successful transition to individualized integrated employment or self-employment, or to supplement such employment and/or self-employment when it is only part-time. Service may involve small group career planning and exploration, small group Discovery classes/activities, other educational opportunities related to successful job acquisition and working successfully in individualized integrated employment. Service may also include employment in integrated business, industry and community settings. Examples include mobile crews, small enclaves and other small groups participating in integrated employment that is specifically related to the identified interests, experiences and/or skills of each of the persons in the small group and that results in acquisition of knowledge, skills and experiences that facilitate transition to individualized integrated employment or self-employment, or that supplement such employment or self-employment when it is only part-time. Minimum staffing ratio is 1:3 for this service.

1. Career planning and exploration activities, Discovery classes/activities, other educational opportunities related to successful job acquisition and working successfully in individualized integrated employment or self-employment must be conducted in appropriate non-disability-specific settings (e.g. Job Centers, businesses, post-secondary education campuses, libraries, etc.) All settings must meet all HCBS setting standards and must not isolate participants from others who do not have disabilities.

2. In the enclave model, a small group of people with disabilities (no more than three people) is trained and supervised to work among employees who are not disabled at the host company's work site. Persons in the enclave may work as a team at a single work area or may work in multiple areas throughout the company. The Supported Employment-Small Group provider is responsible for training, supervision, and support of participants. The provider is expected to conduct this service in integrated business, industry or community settings that meet all HCBS setting standards and do not isolate participants from others in the setting who do not have disabilities. The experience should allow opportunities for routine interactions with others without disabilities in the setting and involvement from supervisors and co-workers without disabilities (not paid to deliver this service) in the supervision and support of individuals receiving this service.

3. In the mobile work crew model, a small crew of workers (including no more than three persons with disabilities and ideally also including workers without disabilities) work as a distinct unit and operate as a self-contained business that generates employment for their crew members by selling a service. The crew typically works at several locations within the community. The Supported Employment-Small Group provider is responsible for training, supervision, and support of participants. The provider is expected to conduct this service in integrated business, industry or community settings that meet all HCBS setting standards and do not isolate participants from others who do not have disabilities. The experience should allow opportunities for routine interactions with people without disabilities (including fellow crew members, customers, etc.) in the course of performing services.

(b) Paid work under Supported Employment-Small Group must be compensated at minimum wage or higher.

(c) Supported Employment-Small Group does not include vocational or prevocational services, employment or training provided in facility based work settings. Supported Employment-Small Group service settings cannot be provider-owned, leased or operated settings. The settings must be integrated in, and support full access of participants to the greater community, including opportunities to learn about and seek individualized integrated employment or self-employment, engage in community life, and control their earned income.

(d) The expected outcome of this service is the acquisition of knowledge, skills and experiences that facilitate career development and transition to individualized integrated employment or self-employment, or that supplement such employment and/or self-employment when it is only part-time. The individualized integrated employment or self-employment shall be consistent with the individual's personal and career goals.

(e) Supported Employment-Small Group services shall be provided in a way that presumes all participants are capable of working in individualized integrated employment and/or self-employment. Participants in this service shall be encouraged, on an ongoing basis, to explore and develop their interests, strengths, and abilities relating to individualized integrated employment and/or self-employment. In order to reauthorize this service, the Person-Centered Support Plan (PCSP) must document that such opportunities are being provided through this service, to the individual, on an on-going basis. The PCSP shall also document and address any barriers to the individual transitioning to individualized integrated employment or self-employment if the person is not already participating in individualized integrated employment or self-employment. Any individual using this service to supplement part-time individualized integrated employment or self-employment shall be offered assistance to increase hours in individualized integrated employment and/or self-employment as an alternative or partial alternative to continuing this service.

(f) As a component part of this service, Supported Employment-Small Group service providers shall support individuals in identifying and pursuing opportunities that will move them into individualized integrated employment or self-employment. A one-time incentive payment for full transition of a person from Supported Employment-Small Group services to individualized integrated employment or self-employment shall be paid to the Supported Employment-Small Group provider upon successful transition (defined as successfully completing at least four weeks in the individualized integrated employment or self-employment situation) out of Supported Employment-Small Group services to individualized integrated employment or self-employment.

(g) Transportation of participants to and from the service is not included in the rate paid for the service; however transportation provided during the course of Supported Employment-Small Group services is considered a component part of the service and the cost of this transportation is included in the rate paid to providers of this service.

(h) The Supported Employment-Small Group provider shall be responsible for any personal assistance needs during the hours that Supported Employment-Small Group services are provided; however, the personal assistance services may not comprise the entirety of the Supported Employment-Small Group service. All providers of personal care under Supported Employment-Small Group shall meet the Personal Assistance service provider qualifications, except that a separate PSSA license shall not be required.

(i) Supported Employment-Small Group services exclude services available to an individual under a program funded under Section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. §§ 1401, et seq.).

(j) Federal financial participation is not claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following:

1. Incentive payments made to an employer to encourage or subsidize the employer's participation in supported employment;

2. Payments that are passed through to users of supported employment services; or

3. Payments for training that is not directly related to an individual's supported employment program.

(k) Supported Employment-Small Group does not include supports provided in facility based (sheltered, prevocational, vocational or habilitation) work settings and does not include supports for volunteering.

(l) Supported Employment-Small Group services shall be limited to no more than 30 hours per week of Supported Employment-Small Group, Integrated Employment Path Services, Community Integration Support Services, and Independent Living Skills training combined.

(211) Supportive Home Care (SHC). For purposes of ECF CHOICES and limited to members enrolled in ECF CHOICES Group 4 (Essential Family Supports) and for purposes of the Katie Beckett Program and limited to children enrolled in Katie Beckett Group Part A or Medicaid Diversion Group Part B:

(a) This service involves the provision of services and supports in the home and community by a paid caregiver who does not live in the family home to an individual living with his or her family that directly assist the individual with activities of daily living and personal needs to insure adequate functioning in their home and maintain community living. Supportive Home Care services may be provided outside of the person's home as long as the outcomes are consistent with the supports defined in the person-centered support plan with the goal of ensuring full participation and inclusion.

(b) Services include:

1. Hands-on assistance with activities of daily living such as dressing/undressing, bathing, feeding, toileting, assistance with ambulation (including the use of a walker, cane, etc.), care of hair and care of teeth or dentures. This can also include preparation and cleaning of areas used during personal care activities such as the bathroom and kitchen.

2. Observation of the person supported to assure safety, oversight direction of the person to complete activities of daily living or instrumental activities of daily living.

3. Routine housecleaning and housekeeping activities performed for the person supported (and not other family members or persons living in the home, as applicable), consisting of tasks that take place on a daily, weekly or other regular basis, including: washing dishes, laundry, dusting, vacuuming, meal preparation and shopping for food and similar activities that do not involve hands-on care of the person.

4. Necessary cleaning of vehicles, wheelchairs and other adaptive equipment and home modifications such as ramps.

(212) Supports Broker. An individual assigned by the FEA to each CHOICES, ECF CHOICES, or Katie Beckett member participating in consumer direction who assists the member/representative as needed in performing certain employer of record functions as follows: developing job descriptions; recruiting, interviewing, and hiring workers; member and worker enrollment in consumer direction and consumer direction training; and developing (as part of the onboarding process for new workers) a schedule for the member's workers that comports with the schedule at which services are needed by the member as reflected in the plan of care or PCSP, as applicable. The supports broker shall also assist the member as needed with developing and verifying the initial back-up plan for consumer direction. The supports broker collaborates with the member's care coordinator or support coordinator, as appropriate. The supports broker does not have authority or responsibility for consumer direction. The member or member's representative must retain authority and responsibility for consumer direction.

(213) TennCare. The program administered by the Single State Agency as designated by the State and CMS pursuant to Title XIX of the Social Security Act and the Section 1115 Research and Demonstration Waiver granted to the State of Tennessee.

(214) TennCare CHOICES in Long-Term Services and Supports Program (CHOICES). The program in which NF services for TennCare eligibles of any age and HCBS for individuals aged sixty-five (65) and older and/or adults aged twenty-one (21) and older with Physical Disabilities are integrated into TennCare's Managed Care System.

(215) TennCare Eligible. For purposes of this Chapter, an individual who has been determined by DHS to be financially eligible to have TennCare reimbursement for covered LTSS.

(216) TennCare Pre-Admission Evaluation Tracking System (PAE Tracking System). A component of the State's Medicaid Management Information System and the system of record for all PreAdmission Evaluation (i.e., level of care) submissions and level of care determinations, as well as enrollments into and transitions between LTSS programs, including CHOICES, ECF CHOICES, and the State's MFP Rebalancing Demonstration (MFP), as a tracking mechanism for referral list management in ECF CHOICES, and which shall also be used to gather data required to comply with tracking and reporting requirements pertaining to MFP.

(217) Third Party Liability (TPL). See "Third Party Liability" in Rule 1200-13-13-.01.

(218) Tracheal Suctioning Reimbursement. The rate of reimbursement provided for NF services, including enhanced respiratory care assistance, delivered by a dual certified NF/SNF that meets the requirements set forth in Rule 1200-13-01-.03(5), to residents determined by the Bureau to meet the medical eligibility criteria set forth in Rule 1200-13-01-.10(5)(d) or determined by their TennCare MCO to require short-term intensive respiratory intervention during the post-weaning period, which shall include documented progress in weaning from the tracheostomy. Tracheal Suctioning Reimbursement shall include two (2) distinct levels of reimbursement as follows:

(a) Secretion Management Tracheal Suctioning Reimbursement for services delivered by a dual certified NF/SNF to persons who meet the medical eligibility criteria set forth in Rule 1200-13-01-.10(5)(d) and have an approved PAE for such level of reimbursement; and

(b) Sub-Acute Tracheal Suctioning Reimbursement for short-term intensive respiratory intervention delivered by a dual certified NF/SNF and determined by the person's TennCare MCO to be medically necessary during the post-weaning period, which shall include documented progress in weaning from the tracheostomy. Because Sub-Acute Tracheal Suctioning Reimbursement provides for intensive respiratory intervention during the period immediately following a person's liberation from the ventilator, Sub-Acute Tracheal Suctioning Reimbursement shall be provided only in a bed specifically licensed for ventilator care.

(219) Transfer Form. For purposes of ICF/IID services and HCBS ID waiver programs, a form approved by the Bureau which is used in lieu of a new PAE to document the transfer of an ICF/IID eligible individual having an approved unexpired ICF/IID PAE from one ICF/IID to another ICF/IID, from an HCBS ID Waiver Program to an ICF/IID, from an ICF/IID to an HCBS ID Waiver Program, or from one HCBS ID Waiver Program to another HCBS ID Waiver Program.

(220) Transition Allowance. For purposes of CHOICES.

(a) A per Member allotment not to exceed two thousand dollars ($2, 000) per lifetime which may, at the sole discretion of an MCO, be provided as a CEA to continued institutional care for a CHOICES Member in order to facilitate transition from a NF to the community when such Member will, upon transition, receive more cost-effective non-residential HCBS or Companion Care.

(b) Items which may be purchased or reimbursed are only those items the Member has no other means to obtain and which are essential in order to establish a community residence when such residence is not already established and to facilitate the person's safe and timely transition, including rent and/or utility deposits, essential kitchen appliances, basic furniture, and essential basic household items, such as towels, linens, and dishes.

(c) Transition Allowance cannot be provided to CHOICES Members transitioning to a CBRA facility.

(221) Vehicle Modification. For purposes of the Katie Beckett Program and limited to children enrolled in Katie Beckett Group Part A or Medicaid Diversion Group Part B.

(a) A structural change or alteration to a vehicle that is the child's primary means of transportation in order to accommodate the unique needs of the child, enable the child's full integration into the community, and ensure the child's health, welfare, and safety.

(b) All modifications shall be based on an assessment and recommendation by a licensed occupational therapist, physician, or other qualified professional and included in the Person-Centered Support Plan.

(c) Vehicle Modifications shall not impede routine local and state safety and emission inspections, as required by law.

(d) Vehicle Modifications shall be limited to no more than $10, 000 per child per year; and $20, 000 per child per lifetime.

(e) The Vehicle Modifications benefit may be combined with other sources of funding such as community grants. Vehicle Modifications in excess of the Katie Beckett benefit limit (which are not covered by TennCare) may be privately paid.

(f) The parent or legal guardian may utilize pre-approved vendors/dealerships for direct billing if they follow the approval and payment process established by the MCO.

(g) Excluded are the following: purchase or lease of a vehicle; upkeep and maintenance of a vehicle; assistance with vehicle registration and licensing; and modifications that are of general utility without direct medical or remedial benefit to the child.

(222) Ventilator Weaning Reimbursement. The rate of reimbursement provided for ventilator weaning services delivered by a NF that meets the requirements set forth in Rule 1200-13-01-.03(5) to residents determined by an MCO to require such services based on medical necessity criteria.

(223) Wait List. The list maintained by NFs of all individuals who have affirmatively expressed an intent to be considered for current or future admission to the NF or requested that their name be entered on any "wait list."

(224) Waiting List. For purposes of CHOICES and Katie Beckett Group Part A and Medicaid Diversion Group Part B, the list maintained by TennCare of individuals who have applied for CHOICES HCBS or for enrollment into the Katie Beckett Program, but who cannot be enrolled into the program (or for Katie Beckett, into the applicable program component) because an Enrollment Target has been reached.

(225) Worker. See "Consumer-Directed Worker."

(Original rule filed November 17, 1977; effective December 19, 1977. Amendment filed December 31, 1979; effective February 14, 1980. Amendment filed May 26, 1983; effective June 27, 1983. Amendment filed September 16, 1987; effective October 31, 1987. Amendment filed November 10, 1988; effective December 25, 1988. Public necessity rule filed January 30, 2006; effective through July 14, 2006. Public necessity rule filed January 30, 2006, expired on July 14, 2006. On July 15, 2006, rule reverted to status in effect on January 29, 2006. Amendment filed May 3, 2006; effective July 17, 2006. Amendment filed January 30, 2007; effective April 15, 2007. Emergency rule filed March 1, 2010; effective through August 28, 2010. Amendment filed May 27, 2010; effective August 25, 2010. Emergency rules filed June 29, 2012; effective through December 26, 2012. Repeal and new rule filed September 26, 2012; effective December 25, 2012. Amendment filed September 26, 2013; effective December 25, 2013. Amendments filed July 28, 2014; effective October 26, 2014. Emergency rule filed June 30, 2015; effective through December 27, 2015. Amendment filed April 14, 2015; effective July 13, 2015. Emergency rule filed July 27, 2015; effective through January 23, 2016. Amendment filed September 23, 2015; effective December 22, 2015. Amendment filed October 22, 2015; effective January 21, 2016. Emergency rules filed July 1, 2016; effective through December 28, 2016. Amendments filed September 30, 2016; effective December 29, 2016. Emergency rules filed November 20, 2020; effective through May 19, 2021.)

Authority: T.C.A. §§ 4-5-202, 4-5-208, 71-5-105, 71-5-106, 71-5-109, 71-5-110, 71-5-111, 71-5-112, and 71-5-164 and TennCare II Section 1115(a) Medicaid Demonstration Waiver Extension.

The following state regulations pages link to this page.