Tenn. Comp. R. & Regs. 1200-11-03-.04 - COVERED AND NON-COVERED SERVICES

(1) When a child enrolled in the program requires services for which one or more third party payors are financially responsible, the program may provide the child with services limited to care coordination, subject to availability of funding.
(2) Covered services are those described in Rule 1200-11-03-.02 that are not covered by third party payors and are limited to those that directly relate to the child's eligible diagnosis. Covered services may include, but are not limited to, the following:
(a) Inpatient hospitalization; outpatient hospitalization or clinic services; care coordination services; orthodontic/dental treatment; drugs, devices and supplies such as medication, and nutritional supplements, standard rehabilitative therapies, assistive technology/augmentative communication devices, co-pays, co-insurance and deductibles; or other support services as determined by the Commissioner and the program;
(b) Subsequent hospitalizations, clinic visits, routine care, transplants and implants deemed medically necessary, medications (including immunosuppressive therapy), and supplies after transplant and implant surgeries; and
(c) Rental or purchase of durable medical equipment; maintenance, repair, or replacement of durable medical equipment; and, where appropriate, training of the enrolled child or the child's family in the use of the equipment.
(3) Services not eligible for reimbursement from the program include, but are not limited to, the following:
(a) Drugs, food and nutritional/dietary supplements not approved by the Food and Drug Administration (FDA);
(b) Orthodontic/Dental services except treatment for eligible cranio-facial (including cleft lip and cleft palate) and designated cardiac diagnoses;
(c) Psychiatric treatment and psychological services; treatment and services for mental, emotional and behavioral disorders, developmental disabilities and learning disabilities;
(d) Treatment for alcohol and drug abuse and/or dependence;
(e) Ambulance fees and transportation costs, except for emergency transportation from one hospital to another, as related to the child's eligible diagnosis;
(f) Services rendered while a child is admitted to a nursing home for continuous or episodic care.
(4) The program shall determine the type and amount of covered services by the availability of funds. When budgetary constraints are indicated the program may:
(a) Create a waiting list of children requesting elective hospital admissions. (The program will evaluate the waiting list on a monthly basis and approve elective admissions according to availability of funds);
(b) Eliminate inpatient hospitalization services as defined in 1200-11-03-.02, except for life-threatening conditions and conditions that would cause a permanent disability, if not treated immediately;
(c) Eliminate services for less severe diagnostic categories as designated by the program; and/or
(d) Reduce the type and amount of support services, durable medical equipment, care coordination, or other covered services.


Tenn. Comp. R. & Regs. 1200-11-03-.04
Original rule filed April 12, 1979; effective May 28, 1979. Repeal and new rule filed December 30, 1983; effective January 29, 1984. Amendment filed May 29, 1990; effective July 13, 1990. Repeal and new rule filed March 21, 2000; effective July 28, 2000. Repeal and new rule filed October 9, 2002; effective December 23, 2002. Amendments filed May 27, 2005; effective September 28, 2005. Repeal and new rules filed September 6, 2016; effective 12/5/2016.

Authority: T.C.A. §§ 4-5-202, 68-1-103, 68-12-101 et seq., and 42 U.S.C. § 704(b)(1).

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