There are three (3) different types of managed care entities
that provide services to TennCare enrollees. Enrollment procedures differ
according to the type of managed care entity, the geographic area, and the
number of managed care entities operating in each geographic area. Enrollment
procedures also differ for ECF CHOICES, as described in subparagraph (c)
TennCare Managed Care
Organizations (MCOs) other than TennCare Select.
Except as provided in subparagraph (c),
individuals or families determined eligible for TennCare shall select a health
plan (Managed Care Organization/MCO) at the time of application. The health
plan must be available in the Grand Division of the State in which the enrollee
lives. All family members living in the same household and enrolled in TennCare
must be assigned to the same MCO except children determined by the Bureau to be
eligible to enroll in TennCare Select. An enrollee is given his choice of MCOs
when possible. If the requested MCO cannot accept new enrollees, the Bureau
will assign each enrollee to an MCO that is accepting new enrollees. If no MCO
is available to enroll new members in the enrollee's Grand Division, the
enrollee will be assigned to TennCare Select until such time as another MCO
becomes available. The Bureau may also assign TennCare children with special
health care needs to TennCare Select.
Individuals enrolled as a result of being eligible for SSI
benefits will be assigned to an MCO as they do not have the opportunity to
select a health plan prior to the effective date of coverage, since they are
enrolled through the Social Security Administration.
2. Except as provided in subparagraph (c), a
TennCare enrollee may change MCOs one (1) time within the initial ninety (90)
calendar days (inclusive of mail time) from the date of the letter informing
him of his MCO assignment, if there is another MCO in the enrollee's Grand
Division that is currently permitted by the Bureau to accept new enrollees. No
additional changes will be allowed except as otherwise specified in these
rules. An enrollee shall remain a member of the designated plan until he is
given an opportunity to change once each year during an annual change period.
The annual change period will occur each year in March for enrollees in West
Tennessee, in May for enrollees in Middle Tennessee, and in July for enrollees
in East Tennessee. Thereafter, an MCO change is permitted only during an annual
change period, unless the Bureau authorizes a change as the result of the
resolution of an appeal requesting a "hardship" reassignment as specified in
paragraph (2)(b) below. When an enrollee changes MCOs, the enrollee's medical
care will be the responsibility of the current MCO until he is enrolled in the
3. Each MCO shall
offer its enrollees, to the extent possible, freedom of choice among
participating providers. If after notification of enrollment the enrollee has
not chosen a primary care provider, one will be selected for him by the MCO.
The period during which an enrollee may choose his primary care provider shall
not be less than fifteen (15) calendar days.
In the event a pregnant woman entering an
MCO's plan is receiving medically necessary prenatal care the day before
enrollment, the MCO shall be responsible for the costs of continuation of such
medically necessary services, without any form of prior approval and without
regard to whether such services are being provided within or outside the MCO's
provider network until such time as the MCO can reasonably transfer the
enrollee to a service and/or network provider without impeding service delivery
that might be harmful to the enrollee's health.
In the event a pregnant woman entering the MCO's plan is in
her second or third trimester of pregnancy and is receiving medically necessary
prenatal care services the day before enrollment, the MCO shall be responsible
for providing continued access to the provider (regardless of network
affiliation) through the postpartum period. Reimbursement to an out-of-network
provider shall be as set out in Rule 1200-13-13-.08.
TennCare Select is a prepaid inpatient health plan (PIHP), as
defined in 42 C.F.R. § 438.2, which operates in all areas of the State and
covers the same services as the MCOs. The State's TennCare Select contractor is
reimbursed on a non-risk, non-capitated basis for services rendered to covered
populations, and in addition receives fees from the State to offset
populations included in the TennCare Select delivery system are as follows:
(i) Children under the age of twenty-one (21)
years who are eligible for Supplemental Security Income.
(ii) Children in state custody and children
leaving state custody for six (6) months post-custody as long as the child
under the age of twenty-one (21) years in an institutional eligibility category
who are receiving care in a Nursing Facility or an Intermediate Care Facility
for persons with Mental Retardation (or pursuant to federal law, Intermediate
Care Facility for the Mentally Retarded) (ICF/MR), and children and adults in a
Home and Community Based Services 1915(c) waiver for individuals with mental
in areas where there is insufficient MCO capacity to serve them.
After being assigned to TennCare Select, persons in
categories (i) and (iii) above may choose to disenroll from TennCare Select and
enroll in another MCO if one is available. Persons in categories (ii) and (iv)
must remain in TennCare Select. TennCare Select is not open to voluntary
selection by TennCare enrollees.
TennCare Select also provides the
(i) It is the back-up
plan should one of the MCOs leave the TennCare program unexpectedly. For
TennCare enrollees previously enrolled with the MCO, TennCare Select provides
medical case management and all MCO covered services.
It is the only entity responsible for
payment of the services described in 42 C.F.R. § 431.52
, services provided
to residents temporarily absent from the State, and provides all MCO covered
services (primarily emergency services).
It is the only entity responsible for
payment of the services described in 42 C.F.R. § 440.255
, limited services
for certain aliens.
TennCare Managed Care Organizations
(MCOs) for ECF CHOICES. Individuals enrolled in ECF CHOICES may select from
only the MCOs participating in ECF CHOICES.
If an individual enrolled in an MCO other than an ECF CHOICES participating MCO
wants to enroll in the ECF CHOICES program, the individual must choose to
enroll in an ECF CHOICES participating MCO in order to enroll in ECF
2. If an individual
enrolled in the ECF CHOICES program elects to transition to an MCO that is not
participating in ECF CHOICES, the individual is choosing to voluntarily
disenroll from ECF CHOICES. Because this is a voluntary decision, advance
notice and the right to a fair hearing shall not be provided. However, the
individual may elect to transition back to an ECF CHOICES participating MCO in
order to resume enrollment in ECF CHOICES.
TennCare Dental Benefits Manager (DBM).
TennCare children shall be assigned to the Dental Benefits
Manager (DBM) under contract with the Bureau to provide dental benefits through
the TennCare Program. Pregnant and postpartum TennCare adults age 21 and older
shall be assigned to the DBM under contract with the Bureau to provide dental
benefits as set out in Rule .04, Dental Services. TennCare adults age 21 and
older enrolled in ECF CHOICES shall be assigned to the DBM under contract with
the Bureau to provide Adult Dental Services through the ECF CHOICES program as
defined in 1200-13-01-.02.
TennCare Pharmacy Benefits Manager (PBM).
TennCare enrollees who are eligible to receive pharmacy
services shall be assigned to the Pharmacy Benefits Manager (PBM) under
contract with the Bureau to provide pharmacy benefits for both medical and
behavioral health services through the TennCare Program.
Reassignment to an MCO other than the
current MCO in which the TennCare enrollee is enrolled is subject to another
MCO's capacity to accept new enrollees and must be approved by the Bureau of
TennCare in accordance with one of the following:
1. During the initial ninety (90) day period
following notification of MCO assignment as described at Rule 1200-13-13-.03, a
TennCare enrollee may request a change of MCOs.
2. A TennCare enrollee must change MCOs if he
moves outside the MCO's Grand Division, and that MCO is not authorized to
operate in the enrollee's new place of residence. Until the TennCare enrollee
selects or is assigned to a new MCO and his enrollment is deemed complete, his
medical care will remain the responsibility of the original MCO.
3. If an enrollee's MCO withdraws from
participation in the TennCare Program, TennCare will assign him to an MCO
operating in his Grand Division, if one is available. The enrollee will be
provided notice of the change and will have ninety (90) days to select another
MCO in his Grand Division. If no MCO is available to accept enrollees from an
exiting plan, the enrollees will be assigned to TennCare Select until such time
as another MCO becomes available.
4. An enrollee shall be given an opportunity
to change MCOs once each year during an annual change period. Only one (1) MCO
change is permitted every twelve (12) months, unless the Bureau authorizes a
change as the result of the resolution of an appeal requesting a "hardship"
reassignment. When an enrollee changes MCOs, the enrollee's medical care will
be the responsibility of the current MCO until enrolled in the requested MCO.
If an enrollee changes MCOs during an annual change period, all family members
living in the same household and enrolled in TennCare shall also be changed
except children enrolled in TennCare Select.
A TennCare enrollee may change MCOs if
the TennCare Bureau has granted a request for a change in MCOs or an appeal of
a denial of a request for a change in MCOs has been resolved in his favor based
on hardship criteria.
situations will not be determined to be "hardships":
(i) The enrollee is unhappy with the current
MCO or primary care provider (PCP), but there is no hardship medical situation
(as stated in Part 2. below);
The enrollee claims lack of access to services but the plan meets the state's
(iii) The enrollee
is unhappy with a current PCP or other providers, and has refused alternative
PCP or provider choices offered by the MCO;
(iv) The enrollee is concerned that a current
provider might drop out of the plan in the future;
(v) The enrollee is a Medicare beneficiary
who (with the exception of pharmacy) may utilize choice of providers,
regardless of network affiliation; or
(vi) The enrollee's PCP is no longer in the
MCO's network, the enrollee wants to continue to see the current PCP and has
refused alternative PCP or provider choices offered by the MCO.
Requests for hardship MCO
reassignments must meet all of the following six (6) hardship criteria for
reassignment. Determinations will be made on an individual basis.
(i) A member has a medical condition that
requires complex, extensive, and ongoing care; and
(ii) The member's specialist has stopped
participating in the member's current MCO network and has refused continuation
of care to the member in his current MCO assignment; and
(iii) The ongoing medical condition of the
member is such that another physician or provider with appropriate expertise
would be unable to take over his care without significant and negative impact
on his care; and
(iv) The current
MCO has been unable to negotiate continued care for this member with the
current specialist; and
current provider of services is in the network of one or more alternative MCOs;
An alternative MCO is
available to enrolled members (i.e., has not given notice of withdrawal from
the TennCare Program, is not in receivership, and is not at member capacity for
the member's region).
Requests to change MCOs submitted by TennCare enrollees shall
be evaluated in accordance with the hardship criteria referenced above. If an
enrollee's request to change MCOs is granted due to hardship, all family
members living in the same household and enrolled in TennCare will be assigned
to the new MCO except children determined by the Bureau to be eligible to
enroll in TennCare Select. Upon denial of a request to change MCOs, enrollees
shall be provided notice and appeal rights as described in applicable
provisions of Rule 1200-13-13-.11.
Members receiving long-term services and
1. In the event that a CHOICES
member is determined, based on an assessment of needs, to require a long-term
care service that is not currently available under the MCO in which he is
currently enrolled, but that is available through another MCO, the Bureau shall
work with the current MCO to arrange for provision of the required service,
which may involve providing such service out-of-network. It shall be considered
to be a hardship reason to change MCO assignment only if the current MCO, after
working with the Bureau, is unable to provide the required service. In such
cases, the MCO that is unable to provide the required service after working
with the Bureau may be subject to sanctions.
A CHOICES or ECF CHOICES member may
request and shall have cause to change MCO assignment if all of the following
(i) The member receives
institutional, residential, or employment support services in the MLTSS program
in which he is enrolled;
member's institutional, residential, or employment support services provider
has stopped participating in the member's MCO network and has refused
continuation of care to the member in his current MCO assignment;
(iii) The member's current MCO has been
unable to negotiate continued services for the member with the current
(iv) The member would
have to change his residential, institutional, or employment supports provider
based on that provider's change in status from an in-network to an
out-of-network provider with the MCO;
(v) As a result, the member would experience
a disruption in his residence or employment;
(vi) The current institutional, residential,
or employment support services provider is in the network of one or more
alternative MCOs; and
alternative MCO the member has selected is available to enroll members (i.e.,
has not given notice of withdrawal from the TennCare Program, is not in
receivership, and is not at member capacity for the member's region).
(d) Enrollees who are
out-of-state on a temporary basis, but maintain their status as Tennessee
residents under federal and state laws, shall be reassigned to TennCare Select
for the period they are out-of-state.
TennCare shall only accept a request to
change MCO assignment from the affected enrollee, his parent, guardian, spouse,
child over age eighteen (18), or responsible party as defined in Rule
When it has been determined
that an individual no longer meets the criteria for TennCare eligibility, that
individual shall be disenrolled from the TennCare Program, including the
CHOICES and ECF CHOICES program, as applicable. Services provided by the
TennCare MCO in which the individual has been enrolled, as well as the PBM and
DBM, if applicable, shall be terminated upon disenrollment. Such disenrollment
action will be accompanied by appropriate due process procedures as described
elsewhere in this Chapter. Disenrollment from the CHOICES program shall proceed
as described in Rule 1200-13-01-.05
. Disenrollment from the ECF CHOICES program
shall proceed as described in Rule 1200-13-01-.31
(b) Coverage shall cease at 12:00 midnight,
local time, on the date that an individual is disenrolled from
TennCare may reassign
individuals from a designated MCO and place them in another MCO as described
elsewhere in these rules. A TennCare MCO may not reassign an enrollee without
the permission of TennCare. A TennCare MCO shall not request the reassignment
of a TennCare enrollee for any of the following reasons:
1. Adverse changes in the enrollee's
2. Pre-existing medical
High cost medical
Coverage by a particular MCO shall cease at 12:00 midnight
local time on the date that an individual has been reassigned by TennCare from
one MCO and placed in another plan. Coverage by the new MCO will begin when
coverage by the old MCO ends.
Tenn. Comp. R. & Regs. 1200-13-13-.03
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
1200-13-13-.03; new effective date February 12, 2003. Emergency rule filed
December 13, 2002; effective through May 27, 2003. Public necessity rule filed
April 29, 2005; effective through October 11, 2005. Amendments filed July 28,
2005; effective October 11, 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. Amendment filed March 31, 2006; effective June 14,
2006. Amendment filed August 14, 2006; effective October 28, 2006. Public
necessity rule filed February 8, 2008; effective through July 22, 2008. Repeal
and new rule filed May 7, 2008; effective July 21, 2008. Amendments filed
September 25, 2009; effective December 24, 2009. Amendment filed November 30,
2009; effective February 28, 2010. Emergency rule filed March 1, 2010;
effective through August 28, 2010. Amendments filed May 27, 2010; effective
August 25, 2010. Amendments filed October 26, 2010; effective January 24, 2011.
Emergency rules filed July 1, 2016; effective through December 28, 2016.
Amendments filed September 30, 2016; effective December 29, 2016. Amendments
filed September 25, 2017; effective December 24, 2017. Amendments filed July 8,
2021; effective October 6, 2021. Amendments filed February 16, 2022; effective
Authority: T.C.A. §§ 4-5-202,
4-5-203, 4-5-208, 4-5-209, 71-5-105, 71-5-107, and 71-5-109 and Executive Order