1200-13-14-.04 - COVERED SERVICES

1200-13-14-.04. COVERED SERVICES

(1) Benefits covered under the managed care program

(a) TennCare MCCs shall cover the following services and benefits subject to any applicable limitations described in this Chapter. TennCare MCCs shall cover TennCare CHOICES services and benefits for individuals enrolled in the TennCare CHOICES program in accordance with Rule 1200-13-01-.05 and ECF CHOICES services and benefits for individuals enrolled in the ECF CHOICES program in accordance with Rule 1200-13-01-.31.

1. Any and all medically necessary services may require prior authorization or approval by the MCC, except where prohibited by law.

2. An MCC shall not refuse to pay for a service solely because of a lack of prior authorization as follows:

(i) Preventive, diagnostic, and treatment services for persons under age 21. MCCs shall provide all medically necessary, covered services regardless of whether the need for such services was identified by a provider whose services had received prior authorization from the MCC or by an in-network provider.

(ii) Emergency services. MCCs shall not require prior authorization or approval for covered services rendered in the event of an emergency, as defined in these rules. Such emergency services may be reviewed on the basis of medical necessity or other MCC administrator requirements, but cannot be denied solely because the provider did not obtain prior authorization or approval from the enrollee's MCC.

3. MCCs shall not impose any service limitations that are more restrictive than those described herein; however, this shall not limit the MCC's ability to establish procedures for the determination of medical necessity.

4. Services for which there is no federal financial participation (FFP) are not covered.

5. Non-covered services are non-covered regardless of medical necessity.

(b) The following physical health and mental health benefits are covered under the TennCare managed care program. Benefits offered under the TennCare CHOICES program are also covered under the TennCare managed care program, as described in Rule 1200-13-01-.05. Benefits offered under the ECF CHOICES program are also covered under the TennCare managed care program, as described in Rule 1200-13-01-.31. There are some exclusions to the benefits listed below. The exclusions are listed in this rule and in Rule 1200-13-14-.10.

SERVICE

BENEFIT FOR PERSONS UNDER AGE 21

BENEFIT FOR PERSONS AGED 21 AND OLDER

1. Ambulance Sevices.

See "Emergency Air and Ground Transportation" and "Non-Emergency Ambulance Transportation."

See "Emergency Air and Ground Transportation" and "Non-Emergency Ambulance Transportation."

2. Bariatric Surgery, defined as surgery to induce weight loss.

Covered as medically necessary.

Covered as medically necessary.

3. Chiropractic Services [defined at 42 C.F.R. § 440.60(b)].

Covered as medically necessary.

Not covered.

4. Community Health Services, [defined at 42 C.F.R. § 440.20(b) and (c) and 42 C.F.R. § 440.90].

Covered as medically necessary.

Covered as medically necessary.

5. Dental Services [defined at 42 C.F.R. § 440.100].

Preventive, diagnostic, and treatment services covered as medically necessary.

Dental services under EPSDT are provided in accordance with the state's periodicity schedule as determined after consultation with recognized dental organizations and at other intervals as medically necessary.

Orthodontic services must be prior authorized by the Dental Benefits Manager (DBM). Orthodontic services are only covered for individuals under age 21. Effective October 1, 2013, TennCare reimbursement for orthodontic treatment approved and begun before age 21 will end on the individual's 21stbirthday. For individuals receiving treatment prior to October 1, 2013, such treatment may continue until completion as long as the enrollee remains eligible for TennCare.

Orthodontic treatment is not covered unless it is medically necessary to treat a handicapping malocclusion. Cleft palate, hemifacial microsomia, or mandibulofacial dysostosis shall be considered handicapping malocclusions.

A TennCare-approved Malocclusion Severity Assessment (MSA) will be conducted to measure the severity of the malocclusion. An MSA score of 28 or higher, as determined by the DBM's dentist reviewer(s), will be used for making orthodontic treatment determinations of medical necessity. However, an MSA score alone cannot be used to deny orthodontic treatment.

Orthodontic treatment will not be authorized for cosmetic purposes. Orthodontic treatment will be paid for by TennCare only as long as the individual remains eligible for TennCare.

The MCO is responsible for the provision of transportation to and from covered dental services, as well as the medical and anesthesia services related to the covered dental services.

Not covered.

6. Durable Medical Equipment [defined at 42 C.F.R. § 440.70(b)(3) and 42 C.F.R. § 440.120(c)].

Covered as medically necessary.

Covered as medically necessary.

7. Emergency Air and Ground Transportation [defined at 42 C.F.R. § 440.170(a)(1) and (3)].

Covered as medically necessary.

Covered as medically necessary.

8. Preventive, Diagnostic, and Treatment Services for Persons Under Age 21.

Screening and interperiodic screening covered in accordance with federal regulations. (Interperiodic screens are screens in between regular checkups which are covered if a parent or caregiver suspects there may be a problem.)

Diagnostic and follow-up treatment services covered as medically necessary and in accordance with federal regulations.

The periodicity schedule for child health screens is that set forth in the latest "American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care." All components of the screens must be consistent with the latest "American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care."

Not applicable.

9. Home Health Care [defined at 42 C.F.R. § 440.70(a), (b), (c), and (e) and at Rule 1200-13-14-.01].

Covered as medically necessary in accordance with the definition of Home Health Care at Rule 1200-13-14-.01. Prior authorization required for home health nurse and home health aide services, as described in Paragraph (7) of this rule.

All home health care must be delivered by a licensed Home Health Agency, as defined by 42 C.F.R. § 440.70.

Covered as medically necessary in accordance with the definition of Home Health Care at Rule 1200-13-14-.01. Prior authorization required for home health nurse and home health aide services, as described in Paragraph (7) of this rule.

All home health care must be delivered by a licensed Home Health Agency, as defined by 42 C.F.R. § 440.70.

10. Hospice Care [defined at 42 C.F.R., Part 418].

Covered as medically necessary.

Must be provided by an organization certified pursuant to Medicare Hospice requirements.

Covered as medically necessary.

Must be provided by an organization certified pursuant to Medicare Hospice requirements.

11. Inpatient and Outpatient Substance Abuse Benefits [defined as services for the treatment of substance abuse that are provided (a) in an inpatient hospital (as defined at 42 C.F.R. § 440.10) or (b) as outpatient hospital services (see 42 C.F.R. § 440.20(a)].

Covered as medically necessary.

Covered as medically necessary.

12. Inpatient Hospital Services [defined at 42 C.F.R. § 440.10].

Covered as medically necessary.

Preadmission and concurrent reviews allowed.

Covered as medically necessary.

Preadmission and concurrent reviews allowed.

13. Inpatient Rehabilitation Facility Services

See "Inpatient Hospital Services."

Not covered.

14. Lab and X-ray Services [defined at 42 C.F.R. § 440.30].

Covered as medically necessary.

Covered as medically necessary.

15. Medical Supplies [defined at 42 C.F.R. § 440.70(b)(3)].

Covered as medically necessary.

Covered as medically necessary.

16. Mental Health Case Management Services [defined as services rendered to support outpatient mental health clinical services].

Covered as medically necessary.

Covered as medically necessary.

17. Mental Health Crisis Services [defined as services rendered to alleviate a psychiatric emergency].

Covered as medically necessary.

Covered as medically necessary.

18. Methadone Clinic Services [defined as services provided by a methadone clinic].

Covered as medically necessary.

Not covered.

19. Non-Emergency Ambulance Transportation, [defined at 42 C.F.R. § 440.170(a)(1) and (3)].

Covered as medically necessary.

Covered as medically necessary.

20. Non-Emergency Transportation [defined at 42 C.F.R. § 440.170(a)(1) and (3)].

Covered as necessary for enrollees lacking accessible transportation for covered services. Emphasis shall be placed on the utilization of fixed route and/or public transportation where appropriate and available.

The travel to access primary care and dental services must meet the requirements of the TennCare demonstration project terms and conditions. The availability of specialty services as related to travel distance should meet the usual and customary standards for the community. However, in the event the MCC is unable to negotiate such an arrangement for an enrollee, transportation must be provided regardless of whether the enrollee has access to transportation.

If the enrollee is a minor child, transportation must be provided for the child and an accompanying adult. However, transportation for a minor child shall not be denied pursuant to any policy which poses a blanket restriction due to enrollee's age or lack of parental accompaniment. Any decision to deny transportation of a minor child due to an enrollee's age or lack of parental accompaniment must be made on a case-by-case basis and must be based on the individual facts surrounding the request. As with any denial, all notices and actions must be in accordance with the appeals process.

Tennessee recognizes the "mature minor exception" to permission for medical treatment.

The provision of transportation to and from covered dental services is the responsibility of the MCO.

For persons dually eligible for Medicare and Medicaid, non-emergency transportation to access medical services covered by Medicare is provided, as long as these services would be covered by TennCare for the enrollee if he did not have Medicare. The Medicare provider of the medical services does not have to participate in TennCare. Transportation to these medical services is covered within the same access standards as those applicable for TennCare enrollees who are not also Medicare beneficiaries.

One escort is allowed per enrollee if the enrollee requires assistance. Assistance is defined for purposes of this rule as help provided to the enrollee that enables the enrollee to receive a medically necessary service. Examples of assistance are: physical assistance such as holding doors or pushing wheelchairs; language assistance such as interpreter services or reading for someone who is illiterate; or decision making assistance. See rule 1200-13-14-.01 for a definition of who may be an escort.

Covered as necessary for enrollees lacking accessible transportation for covered services. Emphasis shall be placed on the utilization of fixed route and/or public transportation where appropriate and available.

The travel to access primary care and dental services must meet the requirements of the TennCare demonstration project terms and conditions. The availability of specialty services as related to travel distance should meet the usual and customary standards for the community. However, in the event the MCC is unable to negotiate such an arrangement for an enrollee, transportation must be provided regardless of whether the enrollee has access to transportation.

For persons dually eligible for Medicare and Medicaid, non-emergency transportation to access medical services covered by Medicare is provided, as long as these services would be covered by TennCare for the enrollee if he did not have Medicare. The Medicare provider of the medical service does not have to participate in TennCare. Transportation to these medical services is covered within the same access standards as those applicable for TennCare enrollees who are not also Medicare beneficiaries.

One escort is allowed per enrollee if the enrollee requires assistance. Assistance is defined for purposes of this rule as help provided to the enrollee that enables the enrollee to receive a medically necessary service. Examples of assistance are: physical assistance such as holding doors or pushing wheelchairs; language assistance such as interpreter services or reading for someone who is illiterate; or decision making assistance. See rule 1200-13-14-.01 for a definition of who may be an escort.

21. Occupational Therapy [defined at 42 C.F.R. § 440.110(b)].

Covered as medically necessary, by a Licensed Occupational Therapist, to restore, improve, stabilize or ameliorate impaired functions.

Covered as medically necessary, by a Licensed Occupational Therapist, to restore, improve, or stabilize impaired functions.

22. Organ and Tissue Transplant Services and Donor Organ/Tissue Procurement Services [defined as the transfer of an organ or tissue from an individual to a TennCare enrollee].

Covered as medically necessary.

Experimental or investigational transplants are not covered.

Covered as medically necessary when coverable by Medicare.

Experimental or investigational transplants are not covered.

23. Outpatient Hospital Services [defined at 42 C.F.R. § 440.20(a)].

Covered as medically necessary.

Covered as medically necessary.

24. Outpatient Mental Health Services (including Physician Services), [defined at 42 C.F.R. § 440.20(a), 42 C.F.R. § 440.50, and 42 C.F.R. § 440.90].

Covered as medically necessary.

Covered as medically necessary.

25. Pharmacy Services [defined at 42 C.F.R. § 440.120(a) and obtained directly from an ambulatory retail pharmacy setting, outpatient hospital pharmacy, mail order pharmacy, or those administered to a long-term care facility (nursing facility) resident].

Covered as medically necessary. Certain drugs (known as DESI, LTE, IRS drugs) are excluded from coverage.

Pharmacy services are the responsibility of the PBM, except for pharmaceuticals supplied and administered in a doctor's office, which are the responsibility of the MCO.

For TennCare Standard children under age 21 who are Medicare beneficiaries, TennCare pays for medically necessary outpatient prescription drugs when they are covered by TennCare but not by Medicare Part D. Pharmaceuticals supplied and administered in a doctor's office to persons under age 21 are the responsibility of the MCO if not covered by Medicare.

(A) Covered as follows, subject to the limitations set out below. Certain drugs known as DESI, LTE or IRS drugs are excluded from coverage. Persons dually eligible for TennCare Standard and Medicare will receive their pharmacy services through Medicare Part D.

(B) Pharmacy services are the responsibility of the PBM, except for pharmaceuticals supplied and administered in the doctor's office. For persons who are not dually eligible for Medicare and Medicaid, pharmaceuticals supplied and administered in a doctor's office are the responsibility of the MCO. For persons who are dually eligible for Medicare and Medicaid, pharmaceuticals supplied and administered in a doctor's office are not covered by TennCare.

(C) For non-Medicare enrollees in the CHOICES 217-Like Group, the CHOICES 1 and 2 Carryover Group, adults age 21 and older enrolled in ECF CHOICES who meet nursing facility level of care or transitioned from a Section 1915(c) waiver into ECF CHOICES and granted an exception by TennCare based on ICF/IID level of care, and the PACE Carryover Group, covered with no quantity limits on the number of prescriptions per month.

(D) For hospice patients, drugs used for the relief of pain and symptom control related to their terminal illness are covered as part of the hospice benefit. If the patient is not a Medicare beneficiary, pharmacy services needed for conditions unrelated to the terminal illness are covered by TennCare. There are no quantity limits on the number of prescriptions per month covered by TennCare if the hospice patient is receiving TennCare-reimbursed room and board in a Nursing Facility. If the patient is receiving hospice services at home or in a residential hospice, coverage of pharmacy services is as described in sections (C) and (E).

(E) For all other non-Medicare enrollees, coverage is limited to five (5) prescriptions and/or refills per enrollee per month, of which no more than two (2) of the five (5) can be brand name drugs. Additional drugs for these enrollees shall not be covered.

(F) Prescriptions shall be counted beginning on the first day of each calendar month. Each prescription and/or refill counts as one (1). A prescription or refill can be for no more than a thirty-one (31) day supply.

(G) The Bureau of TennCare shall maintain an Automatic Exception List of medications which shall not count against such limit. The Bureau of TennCare may modify the Automatic Exception List at its discretion. The most current version of the Automatic Exception List will be made available to enrollees via the internet from the TennCare website and upon request by mail through the DHS Family Assistance Service Center. Only medications that are specified on the current version of the Automatic Exception List that is available on the TennCare website located on the World Wide Web at www.tn.gov/tenncare on the date of service shall be considered exempt from applicable prescription limits.

(H) The Bureau of TennCare shall also maintain a Prescriber Attestation List of medications available when the prescriber attests to an urgent need. The State may include certain drugs or categories of drugs on the list, and may maintain and make available to physicians, providers, pharmacists and the public, a list that shall indicate the drugs or types of drugs the State has determined to include. Drugs on the Prescriber Attestation List may be approved for enrollees who have already met an applicable benefit limit only if the prescribing professional seeks and obtains a special exemption. In order to obtain a special exemption, the prescribing provider must submit an attestation as directed by TennCare regarding the urgent need for the drug. TennCare will approve the prescribing provider's determination that the criteria for the special exemption are met, without further review, within 24 hours of receipt. Enrollees will not be entitled to a hearing regarding their eligibility for a special exemption if (i) the prescribing provider has not submitted the required attestation, or (ii) the requested drug is not on the Prescriber Attestation List.

(I) Pharmacy services in excess of five (5) prescriptions and/or refills per enrollee per month, of which no more than two (2) are brand name drugs, are non-covered services, unless: (a) each excess drug is specified on the current version of the Prescriber Attestation List and a completed Prescriber Attestation is on file for each listed drug as of the date of the pharmacy service; or (b) the excess drug is specified on the Automatic Exception List of medications which shall not count against such limit.

(J) Over-the-counter (OTC) drugs for TennCare adults are not covered even if the enrollee has a prescription for such service, unless the drug is listed on the "Covered OTC Drug List" that is available on the TennCare website located at www.tn.gov/tenncare on the date of service.

26. Physical Therapy [defined at 42 C.F.R. § 440.110(a)].

Covered as medically necessary, by a Licensed Physical Therapist, to restore, improve, stabilize or ameliorate impaired functions,

Covered as medically necessary, by a Licensed Physical Therapist, to restore, improve, or stabilize impaired functions.

27. Physician Inpatient Services [defined at 42 C.F.R. § 440.50].

Covered as medically necessary.

Covered as medically necessary.

28. Physician Outpatient Services/Community Health Clinics/Other Clinic Services [defined at 42 C.F.R. § 440.20(b), 42 C.F.R. § 440.50, and 42 C.F.R. § 440.90].

Covered as medically necessary.

Services provided by a Primary Care Provider when the enrollee has a primary behavioral health diagnosis (ICD-9-CM 290.xx-319.xx) are the responsibility of the MCO.

Medical evaluations provided by a neurologist, as approved by the MCO, and/or an emergency room provider to establish a primary behavioral health diagnosis are the responsibility of the MCO.

Covered as medically necessary, except see "Methadone Clinic Services."

Services provided by a Primary Care Provider when the enrollee has a primary behavioral health diagnosis (ICD-9-CM 290.xx-319.xx) are the responsibility of the MCO.

Medical evaluations provided by a neurologist, as approved by the MCO, and/or an emergency room provider to [LESS THAN] establish a primary behavioral health diagnosis are the responsibility of the MCO.

29. Private Duty Nursing [defined at 42 C.F.R. § 440.80 and at Rule 1200-13-14-.01].

Covered as medically necessary in accordance with the definition of Private Duty Nursing at Rule 1200-13-14-.01, when prescribed by an attending physician for treatment and services rendered by a Registered Nurse (R.N.) or a licensed practical nurse (L.P.N.) who is not an immediate relative. Prior authorization required, as described in Paragraph (7) of this rule.

Covered as medically necessary in accordance with the definition of Private Duty Nursing at Rule 1200-13-14-.01, when prescribed by an attending physician for treatment and services rendered by a Registered Nurse (R.N.) or a licensed practical nurse (L.P.N.) who is not an immediate relative. Private duty nursing services are limited to services that support the use of ventilator equipment or other life-sustaining technology when constant nursing supervision, visual assessment, and monitoring of both equipment and patient are required. Prior authorization required, as described in Paragraph (7) of this rule.

30. Psychiatric Inpatient Facility Services [defined at 42 C.F.R. § 441, Subparts C and D and including services for persons of all ages].

Covered as medically necessary,

Preadmission and concurrent reviews by the MCC are allowed.

Covered as medically necessary,

Preadmission and concurrent reviews by the MCC are allowed.

31. Psychiatric Pharmacy.

See "Pharmacy Services."

See "Pharmacy Services."

32. Psychiatric Rehabilitation Services [defined as psychiatric services delivered in accordance with 42 C.F.R. § 440.130(d)].

Covered as medically necessary.

Covered as medically necessary.

33. Psychiatric Physician Inpatient Services [defined at 42 C.F.R. § 440.50].

Covered as medically necessary.

Covered as medically necessary.

34. Psychiatric Physician Outpatient Services.

See "Outpatient Mental Health Services."

See "Outpatient Mental Health Services."

35. Psychiatric Residential Treatment Services [defined at 42 C.F.R. § 483.352] and including services for persons of all ages].

Covered as medically necessary.

Covered as medically necessary.

36. Reconstructive Breast Surgery [defined in accordance with Tenn. Code Ann. § 56-7-2507].

Covered in accordance with Tenn. Code Ann. § 56-7-2507 which requires coverage of all stages of reconstructive breast surgery on a diseased breast as a result of a mastectomy as well as any surgical procedure on the non-diseased breast deemed necessary to establish symmetry between the two breasts in the manner chosen by the physician. The surgical procedure performed on a non-diseased breast to establish symmetry with the diseased breast will only be covered if the surgical procedure performed on a non-diseased breast occurs within five (5) years of the date the reconstructive breast surgery was performed on a diseased breast.

Covered in accordance with Tenn. Code Ann. § 56-7-2507 which requires coverage of all stages of reconstructive breast surgery on a diseased breast as a result of a mastectomy as well as any surgical procedure on the non-diseased breast deemed necessary to establish symmetry between the two breasts in the manner chosen by the physician. The surgical procedure performed on a non-diseased breast to establish symmetry with the diseased breast will only be covered if the surgical procedure performed on a non-diseased breast occurs within five (5) years of the date the reconstructive breast surgery was performed on a diseased breast.

37. Rehabilitation services

See "Occupational Therapy, " "Physical Therapy, " and "Speech Therapy, " and "Inpatient Rehabilitation Facility Services"

See "Occupational Therapy, " "Physical Therapy, " and "Speech Therapy."

38. Renal Dialysis Clinic Services [defined at 42 C.F.R. § 440.90].

Covered as medically necessary. Generally limited to the beginning ninety (90) day period prior to the enrollee's becoming eligible for coverage by the Medicare program.

Covered as medically necessary. Generally limited to the beginning ninety (90) day period prior to the enrollee's becoming eligible for coverage by the Medicare program.

39. Speech Therapy [defined at 42 C.F.R. § 440.110(c)].

Covered as medically necessary, by a Licensed Speech Therapist to restore, improve, stabilize or ameliorate impaired functions.

Covered as medically necessary, as long as there is continued medical progress, by a Licensed Speech Therapist to restore speech after a loss or impairment.

40. Transportation.

See "Emergency Air and Ground Transportation, " "Non-Emergency Ambulance Transportation, " and "Non-Emergency Transportation."

See "Emergency Air and Ground Transportation, " "Non-Emergency Ambulance Transportation, " and "Non-Emergency Transportation."

41. Vision Services [defined as services to treat conditions of the eyes].

Preventive, diagnostic, and treatment services (including eyeglasses) covered as medically necessary.

Medical eye care, meaning evaluation and management of abnormal conditions, diseases, and disorders of the eye (not including evaluation and treatment of the refractive state) is covered. Routine, periodic assessment, evaluation or screening of normal eyes, and examinations for the purpose of prescribing, fitting, or changing eyeglasses and/or contact lenses are not covered.

One pair of cataract glasses or lenses is covered for adults following cataract surgery.

(c) Pharmacy TennCare is permitted under the terms and conditions of the demonstration project approved by the federal government to restrict coverage of prescription and non-prescription drugs to a TennCare-approved list of drugs known as a drug formulary. TennCare must make this list of covered drugs available to the public. Through the use of a formulary, the following drugs or classes of drugs, or their medical uses, shall be excluded from coverage or otherwise restricted by TennCare as described in Section 1927 of the Social Security Act [42 U.S.C. § 1396r-8]:

1. Agents for weight loss or weight gain.

2. Agents to promote fertility or for the treatment of impotence or infertility or for the reversal of sterilization.

3. Agents for cosmetic purposes or hair growth.

4. Agents for symptomatic relief of coughs and colds.

5. Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations.

6. Nonprescription drugs.

7. Covered outpatient drugs, which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or his designee.

8. TennCare shall not cover drugs considered by the FDA to be Less Than Effective (LTE) and DESI drugs, or drugs considered to be Identical, Related and Similar (IRS) to DESI and LTE drugs or any other pharmacy services for which federal financial participation (FFP) is not available. The exclusion of drugs for which no FFP is available extends to all TennCare enrollees regardless of the enrollee's age. TennCare shall not cover experimental or investigational drugs which have not received final approval from the FDA.

9. Buprenorphine products for opiate addiction treatment for persons aged 21 and older are restricted as follows:

(i) Dosage shall not exceed sixteen milligrams (16 mg) per day for a period of up to six (6) months from the initiation of therapy.

(ii) For enrollees who are pregnant while receiving the sixteen milligrams (16 mg) per day dosage, the six-month period does not begin until the enrollee is no longer pregnant.

(iii) At the end of the six-month period described in subparts (i) and (ii), the covered dosage amount shall not exceed eight milligrams (8 mg) per day.

10. Sedative hypnotic medications for persons aged 21 and older shall not exceed fourteen (14) pills per month for sedative hypnotic formulations in pill form such as Ambien and Lunesta, one hundred forty milliliters (140 ml) per month of chloral hydrate, or one (1) bottle every sixty (60) days of Zolpimist.

11. Allergy medications.

12. Opioid products for persons aged twenty-one (21) and older are restricted as follows:

(i) "Chronic opioid user" means:

(I) A TennCare enrollee whose TennCare paid claims data demonstrates that he has received at least a ninety (90) day quantity of prescribed opioids in the one hundred eighty (180) day period immediately preceding the opioid's prescription date.

(II) For a TennCare enrollee who has not been enrolled in TennCare long enough to demonstrate that he is a chronic opioid user as defined in Item (I), the enrollee may demonstrate that he has received at least a ninety (90) day quantity of prescribed opioids in the one hundred eighty (180) day period immediately preceding the opioid's prescription date by supplying paid claims data and medical records from his previous healthcare provider(s) or health insurer(s).

(ii) "Non-chronic opioid user" means a TennCare enrollee whose TennCare paid claims data demonstrates he has received less than a ninety (90) day quantity of prescribed opioids in the one hundred eighty (180) day period immediately preceding the opioid's prescription date.

(iii) Non-chronic opioid users shall be eligible to receive covered prescription opioid products as follows:

(I) A maximum of fifteen (15) dosage days in any six (6) month period; and

(II) Daily dosage shall not exceed sixty (60) morphine milligram equivalents (MME) per day.

(iv) The restrictions in Subpart (iii) do not apply for enrollees with severe cancer pain undergoing active or palliative cancer treatment and enrollees in hospice and palliative care.

(v) The following considerations apply for enrollees who experience more frequent or aggressive pain episodes due to these specific clinical disease states:

(I) Enrollees with Sickle Cell may receive up to forty-five (45) days of sixty (60) MME per day in any ninety (90) day period; and

(II) Severe burn victims may receive up to forty-five (45) days of sixty (60) MME per day in any ninety (90) day period.

(vi) Notwithstanding the restrictions in Subpart (iii), enrollees residing in a Med-icaid-certified Nursing Facility may receive up to forty-five (45) days of sixty (60) MME per day in any ninety (90) day period.

(vii) Opioid prescriptions are subject to prior authorization following the first fill of a new opioid prescription.

(viii) For women of child-bearing age (between the ages of fifteen (15) and forty-four (44)) and ability, when prior authorization is required for an opioid prescription, the prescribing provider must submit information to the enrollee's PBM regarding the enrollee's pregnancy status and use of contraception or family planning methods, and the provision of counseling regarding the risks of becoming pregnant while receiving opioid medication. The information regarding pregnancy status and contraceptive use may, when appropriate, be based on self-reporting by the patient.

(d) The MCC shall be allowed to provide cost effective alternative services as defined in paragraph 1200-13-14-.01(33). Cost effective alternative services are not reimbursable in any circumstances other than those described in that paragraph.

(2) Use of Cost Effective Alternative Services.

(a) MCCs shall be allowed, but are not required, to use cost effective alternative services if and only if:

1. These services are listed in the MCC contract and/or in Policy BEN 08-001; or

2. These services are provided under the CHOICES program for individuals enrolled in the CHOICES program in accordance with Rule 1200-13-01-.05 or the ECF CHOICES program for individuals enrolled in the ECF CHOICES program in accordance with Rule 1200-13-01-.31; and

3. They are medically appropriate and cost effective.

(b) Use of approved cost effective alternative services is made at the sole discretion of the MCC.

(3) Emergency Medical Services.

Emergency medical services shall be available twenty-four (24) hours per day, seven (7) days per week. Coverage of emergency medical services shall not be subject to prior authorization by the MCC but may include a requirement that notice be given to the MCC of use of out-of-plan emergency services. However, such requirements shall provide at least a twenty-four (24) hour time frame after the emergency for notice to be given to the MCC.

(4) Preventive, Diagnostic and Treatment Services for Individuals Under Twenty-One (21).

The Bureau of TennCare, through its contracts with Managed Care Organizations (MCOs) and other contractors (also referred to collectively as Contractors), operates an EPSDT program to provide health care services as required by 42 C.F.R. Part 441, Subpart B and the "Omnibus Budget Reconciliation Act of 1989" to eligible enrollees under the age of 21.

(a) Responsibilities of the Bureau of TennCare

1. The Bureau will:

(i) Keep Contractors informed as to changes to the requirements for the operation of the EPSDT program;

(ii) Make changes to the rules of TennCare when necessary to keep the EPSDT program in compliance with federal and state requirements;

(iii) Provide policy clarification when needed; and

(iv) Oversee the activities of the Contractors to assure compliance with all aspects of the EPSDT program.

2. The Bureau, through local health departments, shall inform families of uninsured children who are enrolled in TennCare, of the benefits covered under TennCare and the importance of accessing preventive services.

3. The Bureau, through local health departments, shall provide information on covered services to adolescent prenatal patients who enter TennCare through presumptive eligibility. Assistance will be offered to presumptive eligibles on the day eligibility is determined in making a timely first prenatal appointment; for a woman past her first trimester, this appointment should occur within fifteen (15) days.

4. The Bureau, through the Department of Children's Services, shall inform foster parents and institutions or other residential treatment settings with a number of eligible children, annually or more often when the need arises, including when a change of administrators, social workers, or foster parents occur, of the availability of EPSDT services.

(b) Responsibilities of Contractors

1. Contractors shall aggressively and effectively inform enrollees of the existence of the EPSDT program, including the availability of specific EPSDT screening and treatment services. Such informing shall occur in a timely manner, generally within sixty (60) days of the MCO's receipt of notification of the child's enrollment in its plan and if no one eligible in the family has utilized EPSDT services, at least annually thereafter.

Contractors shall document to the Bureau the contractor's outreach activities and what efforts were made to inform enrollees and/or the enrollee's responsible party about the availability of EPSDT services and how to access such services. Failure to timely submit the requested data may result in liquidated damages as described in the contracts between the Bureau of TennCare and the Contractors.

2. Contractors shall use clear and non-technical terms to provide a combination of written and oral information so that the program is clearly and easily understandable.

3. Contractors shall use effective methods (developed through collaboration with agencies which have established procedures for working with such individuals) to inform individuals who are illiterate, blind, deaf, or cannot understand English, about the availability of EPSDT services.

4. Contractors shall design and conduct outreach to inform all eligible individuals about what services are available under EPSDT, the benefits of preventive health care, where services are available, and how to obtain them; and that necessary transportation and scheduling assistance is available.

5. Contractors shall create a system so that families can readily access an accurate list of names and phone numbers of contract providers who are currently accepting TennCare.

6. Contractors shall offer both transportation and scheduling assistance prior to the due date of the child's periodic examination.

7. Contractors shall provide enrollees assistance in scheduling appointments and obtaining transportation prior to the date of each periodic examination as requested and necessary.

8. Contractors shall document services declined by a parent or guardian or a mature competent child, specifying the particular service declined so that outreach and education for other EPSDT services continues.

9. Contractors shall maintain records of the efforts taken to outreach children who have missed screening appointments when scheduled or who have failed to schedule regular check-ups. These records shall be made available to the Bureau and other parties as directed by TennCare.

10. Contractors shall inform families of the costs, if any, of EPSDT services.

11. Contractors shall treat a TennCare-eligible woman's request for EPSDT services during pregnancy as a request for EPSDT services for the child at birth.

(c) Compliance

Contractors must document and maintain records of all outreach efforts made to inform enrollees about the availability of EPSDT services.

(5) Preventive Medical Services. The following services (identified by applicable CPT procedure codes) shall be covered subject to any limitations described herein, within the scope of standard medical practice, without copay.

(a) Office Visits

1. New Patient

99381 - Initial evaluation

99382 - ages 1 through 4 years

99383 - ages 5 through 11 years

99384 - ages 12 through 17 years

99385 - ages 18 through 39 years

99386 - ages 40 through 64 years

99387 - ages 65 years and older

2. Established Patient

99391 - Periodic evaluation

99392 - ages 1 through 4 years

99393 - ages 5 through 11 years

99394 - ages 12 through 17 years

99395 - ages 18 through 39 years

99396 - ages 40 through 64 years

99397 - ages 65 years and older

(b) Counseling and Risk Factor Reduction Intervention

1. Individual

99401 - approximately 15 minutes

99402 - approximately 30 minutes

99403 - approximately 45 minutes

99404 - approximately 60 minutes

2. Group

99411 - approximately 30 minutes

99412 - approximately 60 minutes

(c) Family Planning Services, if not part of a preventive services office visit, should be billed by using the codes in (b)1. above.

(d) Mental health case management services including T1016 and H0004.

(e) Vaccines as recommended by the Advisory Committee on Immunization Practices (ACIP).

(f) Any other covered service assigned a rating of A or B by the US Preventative Services Task Force (USPSTF).

(6) Hospital Discharges.

Hospital discharges of mothers and newborn babies following delivery shall take into consideration the following guidelines:

(a) The decision to discharge postpartum mothers and newborns less than 24-48 hours after delivery should be made based upon discharge criteria collaboratively developed and adopted by obstetricians, pediatricians, family practitioners, delivery hospitals, and health plans. The criteria must be contingent upon appropriate preparation, meeting in hospital criteria for both mother and baby, and the planning and implementation of appropriate follow-up. An individualized plan of care must include identification of a primary care provider for both mother and baby and arrangements for follow-up evaluation of the newborn.

Length of hospital stay is only one factor to consider when attempting to optimize patient outcomes for postpartum women and newborns. Excellent outcomes are possible even when length of stay is very brief (less than 24 hours) if perinatal health care is well planned, allows for continuity of care, and patients are well chosen. Some postpartum patients and/or newborns may require extended hospitalization (greater than 48-72 hours) despite meticulous care due to medical, obstetric, or neonatal complications. The decision for time of discharge must be individualized and made by the physicians caring for the mother-baby pair. The following guidelines have been developed to aid in the identification of postpartum mothers and newborns who may be candidates for discharge prior to 24-48 hours. The guidelines also provide examples where discharge is inappropriate.

Principles of patient care should be based upon data obtained by clinical research. Regarding the question of postpartum and newborn length of hospitalization, there are inadequate studies available to provide clear direction for clinical decision-making. Clinical guidelines represent an attempt to conceptualize what is, in reality, a dynamic process of health care refinement. Review of these guidelines is desirable and expected.

No provider shall be denied participation, reimbursement or reduction in reimbursement within a network solely related to his/her compliance with the "Guidelines for Discharge of Postpartum Mothers and Newborns."

(b) Guidelines for Discharge of Postpartum Mothers and Newborns

1. Discharge Planning.

(i) Discharge planning should occur in a planned and systematic fashion for all postpartum women and newborns in order to enhance care, prevent complications and minimize the need for rehospitalization. Prior to discharge a discussion should be held between the physician or another health care provider and the mother (and father if possible) about any expected perinatal problems and ways to cope with them. Plans for future and immediate care as well as instructions to follow in the event of an emergency or complication should be discussed.

Follow-up care must be planned for both mother and baby at the time of discharge. For patients leaving the hospital prior to 24-48 hours, contact within 48-72 hours of discharge is recommended and may include appropriate follow-up within 48-72 hours as deemed necessary by the attending provider, depending upon individual patient need. This follow-up visit will be acknowledged as a provider encounter.

(I) Maternal Considerations:

I. Prior to discharge, the patient should be informed of normal postpartum events including but not limited to:

A. Lochial patterns;

B. Range of activity and exercise;

C. Breast care;

D. Bladder care;

E. Dietary needs;

F. Perineal care;

G. Emotional responses;

H. What to report to physician or other health care provider including:

(A) Elevation of temperature,

(B) Chills,

(C) Leg pains, and

(D) Increased vaginal bleeding.

I. Method of contraception;

J. Coitus resumption; and

K. Specific instructions for follow-up (routine and emergent)

(II) Neonatal Considerations:

I. Prior to discharge, the following points should be reviewed with the mother or, preferably, with both parents:

A. Condition of the neonate;

B. Immediate needs of the neonate; (e.g., feeding methods and environmental supports);

C. Instructions to follow in the event of a newborn complication or emergency;

D. Feeding techniques: skin care, including cord care and genital care; temperature assessment and measurement with the thermometer; and assessment of neonatal well-being; recognition of illness including jaundice; proper infant safety including use of car seat and sleeping position;

E. Reasonable expectations for the future; and

F. Importance of maintaining immunization begun with initial dose of hepatitis B vaccine.

2. Criteria for Maternal Discharge Less Than 24-48 Hours Following Delivery.

(i) Prior to discharge of the mother, the following should occur:

(I) The mother should have been observed after delivery for a sufficient time to ensure that her condition is stable, that she has sufficiently recovered and may be safely transferred to outpatient care.

(II) Laboratory evaluations should be obtained and include ABO blood group and Rh typing with appropriate use of Rh immune globulin; and hematocrit or hemoglobin.

(III) The mother should have received adequate preparation for and be able to assume self and immediate neonatal care.

(ii) Factors which may exclude maternal discharge prior to 24-48 hours include:

(I) Abnormal bleeding.

(II) Fever equal to or greater than 100.4 degrees.

(III) Inadequate or no prenatal care.

(IV) Cesarean section.

(V) Untreated or unstable maternal medical condition.

(VI) Uncontrolled hypertension.

(VII) Inability to void.

(VIII) Inability to tolerate solid foods.

(IX) Adolescent mother without adequate support and where appropriate follow-up has not been established. A nurse home visit within 24-48 hours of discharge would act as appropriate follow-up.

(X) All efforts should be made to keep mother and infant together to ensure simultaneous discharge.

(XI) Psychosocial problems (maternal or family) which have been identified prenatally or in hospital. Where appropriate follow-up has not been established, a nurse home visit within 24-48 hours of discharge would act as appropriate follow-up.

3. Criteria for Neonatal, Discharge Less than 24-48 Hours Following Delivery.

(i) The nursery stay is planned to allow the identification of early problems and to reinforce instruction in preparation for care of the infant at home. Complications often are not predictable by prenatal and intrapartum events. Because many neonatal problems do not become apparent until several days after birth there is an element of medical risk in early neonatal discharge. Most problems are manifest during the first twelve (12) hours, and discharge at or prior to twenty-four (24) hours is appropriate for many new-borns.

(I) Prior to discharge of the newborn at 24-48 hours, the following should have occurred:

I. The course of antepartum, intrapartum, and postpartum care for both mother and fetus should be without problems, which may lead to newborn complications.

II. The baby is a single birth at 37 to 42 weeks' gestation and the birth weight is appropriate for gestational age according to appropriate intrauterine growth curves.

III. The baby's vital signs are documented as being normal and stable for the twelve (12) hours preceding discharge, including a respiratory rate below 60/minute, a heart rate of 100 to 160 beats per minute, and an axillary temperature of 36.1 degrees C in an open crib with appropriate clothing.

IV. The baby has urinated and passed at least one stool.

V. No evidence of excessive bleeding after circumcision greater than two (2) hours.

VI. The baby has completed at least two successful feedings, with documentation that the baby is able to coordinate sucking, swallowing, and breathing while feeding.

VII. No evidence of significant jaundice in the first twenty-four (24) hours of life.

VIII. The parent's or caretaker's knowledge, ability, and confidence to provide adequate care for her baby are documented.

IX. Laboratory data are available and reviewed including:

A. Maternal syphilis and hepatitis B surface antigen status.

B. Cord or infant blood type and direct Coomb's test result as clinically indicated.

X. Screening tests are performed in accordance with state regulations. If the test is performed before twenty-four (24) hours of milk feeding, a system for repeating the test must be assured during the follow-up visit.

XI. Initial hepatitis B vaccine is administered or a scheduled appointment for its administration has been made.

XII. A physician-directed source of continuing medical care for both the mother and the baby is identified. For newborns discharged less than 24-48 hours after delivery, a definitive plan for contact within 48-72 hours after discharge has been made. A nurse home visit within 24-48 hours would be considered appropriate follow-up.

(II) Maternal factors which may exclude discharge of the newborn prior to 24-48 hours include:

I. Inadequate or no prenatal care,

II. Medical conditions that pose a significant risk to the infant,

III. Group B streptococcus colonization,

IV. Untreated syphilis,

V. Suspected active genital herpes,

VI. HIV,

VII. Adolescent without adequate support and where appropriate follow-up has not been established (a nurse home visit within 24-48 hours of discharge will act as appropriate follow-up),

VIII. Mental retardation or psychiatric illness, and

IX. Requirements for continued maternal hospitalization.

(III) Newborn factors which may exclude discharge of the newborn prior to 24-48 hours include:

I. Preterm gestation (less than 37 weeks);

II. Small for gestational age;

III. Large for gestational age;

IV. Abnormal physical exam, vital signs, color, activity, feeding or stooling;

V. Significant congenital malformations; and

VI. Abnormal laboratory finding:

A. Hypoglycemia,

B. Hyperbilirubinemia,

C. Polycythemia,

D. Anemia, and

E. Rapid plasma reagin positive.

(7) Prior Authorization for Home Health Nurse, Home Health Aide, and Private Duty Nursing Services. Prior authorization by the MCC must be obtained in order to establish the medical necessity of all requested home health nurse, home health aide, and private duty nursing services.

(a) The following information must be provided when seeking prior authorization for home health nurse, home health aide, and private duty nursing services:

1. Name of physician prescribing the service(s);

2. Specific information regarding the patient's medical condition and any associated disability that creates the need for the requested service(s); and

3. Specific information regarding the service(s) the nurse or aide is expected to perform, including the frequency with which each service must be performed (e.g., tube feeding patient 7:00 a.m., 12:00 p.m., and 5:00 p.m. daily; bathe patient once per day; administer medications three (3) times per day; catheterize patient as needed from 8:00 a.m. to 5:00 p.m. Monday through Friday; change dressing on wound three (3) times per week). Such information should also include the total period of time that the services are anticipated to be medically necessary by the treating physician (e.g., total number of weeks or months).

(b) Home health nurses and aides and private duty nurses will never be authorized to personally transport a TennCare enrollee. Home health nurses and aides delivering prior approved home health care services may accompany an enrollee outside the home in accordance with T.C.A. § 71-5-107(a)(12).

(c) Private duty nursing services are limited to services provided in the recipient's own home, with the following two exceptions:

1. A recipient age twenty-one (21) or older who requires eight (8) or more hours of skilled nursing care in a 24-hour period and is authorized to receive private duty nursing services in the home setting may make use of the approved hours outside of that setting in order for the nurse to accompany the recipient to:

(i) Outpatient health care services (including services delivered through a TennCare home and community based services waiver program);

(ii) Public or private secondary school or credit classes at an accredited vocational or technical school or institute of higher education; or,

(iii) Work at his place of employment.

2. A recipient under the age of twenty-one (21) who requires eight (8) or more hours of continuous skilled nursing care in a 24-hour period and is authorized to receive those services in the home setting may make use of the approved hours outside of that setting when normal life activities temporarily take him outside of that setting. Normal life activity for a child under the age of twenty-one (21) means routine work (including work in supported or sheltered work settings); licensed child care; school and school-related activities; religious services and related activities; and outpatient health care services (including services delivered through a TennCare home and community based services waiver program). Normal life activities do not include non-routine or extended home absences.

(d) A private duty nurse may accompany a recipient in the circumstances outlined in subparagraph (c) immediately above, but may not drive.

(e) Private duty nursing services will only be authorized when there are competent family members or caregivers as indicated below:

1. Private duty nursing services include services to teach and train the recipient and the recipient's family or other caregivers how to manage the treatment regimen. Having a caregiver willing to learn the tasks necessary to provide a safe environment and quality in home care is essential to assuring the recipient is properly attended to when a nurse or other paid caregiver is not present, including those times when the recipient chooses to attend community activities to which these rules do not specifically permit the private duty nurse or other paid caregiver to accompany the patient.

2. To ensure the health, safety, and welfare of the individual, in order to receive private duty nursing services, the recipient must have family or caregivers who:

(i) Have a demonstrated understanding, ability, and commitment in the care of the individual related to ventilator management, support of other life-sustaining technology, medication administration and feeding, or in the case of children, other medically necessary skilled nursing functions, as applicable; and

(ii) Are trained and willing to meet the recipient's nursing needs during the hours when paid nursing care is not provided, and to provide backup in the event of an emergency; and

(iii) Are willing and available as needed to meet the recipient's non-nursing support needs.

(iv) In the case of children under the age of 18, the parent or guardian will be expected to fill this role. In the case of an adult age 18 and older, if the health, safety, and welfare of the individual cannot be assured because the recipient does not have such family or caregiver, private duty nursing services may be denied, subject to items (I) and (II) below. However, it shall be the responsibility of the MCO to:

(I) Arrange for the appropriate level of care, which may include nursing facility care, if applicable; and

(II) In the case of a person currently receiving private duty nursing services, facilitate transition to such appropriate level of care prior to termination of the private duty nursing service.

(f) Nursing services (provided as part of home health services or by a private duty nurse) will be approved only if the requested service(s) is of the type that must be provided by a nurse as opposed to an aide, except that the MCO may elect to have a nurse perform home health aide services in addition to nursing services if the MCO determines that this is a less costly alternative than providing the services of both a nurse and an aide. Examples of appropriate nursing services include, but are not limited to, management of ventilator equipment or other life-sustaining medical technology, medication management, and tube feedings.

(g) Home health aide services will only be approved if the requested service(s) meet all medical necessity requirements including the requirements of 1200-13-16-.05(4)(d). Thus, home health aide services will not be approved to provide child care services, prepare meals, perform housework, or generally supervise patients. Examples of appropriate home health aide services include, but are not limited to, patient transfers and bathing.

(Public necessity rule filed July 1, 2002; effective through December 13, 2002. Original rule filed September 30, 2002; to be effective December 14, 2002; however, on December 9, 2002, the House Government Operations Committee of the General Assembly stayed rule 1200-13-14-.04; new effective date February 12, 2003. Emergency rule filed December 13, 2002; effective through May 27, 2003. Public necessity rule filed July 1, 2005; effective through December 13, 2005. Amendments filed September 29, 2005; effective December 13, 2005. Public necessity rule filed December 29, 2005; expired June 12, 2006. On June 13, 2006, affected rules reverted to status on December 28, 2005. Public necessity rule filed March 13, 2006; effective through August 25, 2006. Public necessity rule filed May 3, 2006; effective through October 15, 2006. Amendments filed March 31, 2006; effective June 14, 2006. Amendment filed June 12, 2006; effective August 26, 2006. Amendment filed July 28, 2006; effective October 11, 2006. Public necessity rule filed December 1, 2006; effective through May 15, 2007. Public necessity rule filed February 1, 2007; effective through July 16, 2007. Amendment filed February 2, 2007; effective April 18, 2007. Amendment filed May 2, 2007; effective July 16, 2007. Public necessity rule filed October 11, 2007; effective through March 24, 2008. Public necessity rule filed February 8, 2008; effective through July 22, 2008. Amendment filed May 7, 2008; effective July 21, 2008. Public necessity rule filed September 8, 2008; effective through February 20, 2009. Amendments filed August 19, 2008; effective November 2, 2008. Amendment filed December 5, 2008; effective February 18, 2009. Public necessity rule filed July 1, 2009; effective through December 13, 2009. Amendment filed June 11, 2009; effective August 25, 2009. Amendment filed September 11, 2009; effective December 10, 2009. Amendments filed September 25, 2009; effective December 24, 2009. Amendments filed September 30, 2009; effective December 29, 2009. Emergency rule filed March 1, 2010; effective through August 28, 2010. Amendments filed May 27, 2010; effective August 25, 2010. Amendment filed October 26, 2010; effective January 24, 2011. Emergency rules filed July 1, 2011; effective through December 28, 2011. Emergency rule filed August 2, 2011; effective through January 29, 2012. Amendments filed September 23, 2011; effective December 22, 2011. Amendment filed October 28, 2011; effective January 26, 2012. Amendment filed August 10, 2011; effective January 29, 2012. Amendment filed April 25, 2012; effective September 28, 2012. Emergency rule filed September 27, 2013; effective through March 26, 2014. Amendments filed July 1, 2013; effective September 29, 2013. Amendment filed August 7, 2013; effective November 5, 2013. Amendment filed September 27, 2013; effective December 26, 2013. Amendment filed December 17, 2013; effective March 17, 2014. Amendment filed June 17, 2014; effective September 15, 2014. Emergency rule filed September 30, 2015; effective through March 28, 2016. Amendments filed December 29, 2015; effective March 28, 2016. Emergency rules filed June 24, 2016; effective through December 21, 2016. Emergency rules filed July 1, 2016; effective through December 28, 2016. Amendments filed September 13, 2016; effective December 12, 2016. Amendments filed September 30, 2016; effective December 29, 2016. Emergency rules filed January 16, 2018; effective through July 15, 2018. Amendments filed April 9, 2018; effective July 8, 2018. Amendments filed January 3, 2019; effective April 3, 2019.)

Authority: T.C.A. §§ 4-5-202, 4-5-208, 4-5-209, 71-5-105, 71-5-109, 71-5-197, Executive Order No. 23, and Public Chapter 473, Acts of 2011.

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