.
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)
below.
(a) TennCare Managed Care
Organizations (MCOs) other than
TennCare Select.
1. 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
requested MCO.
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.
4. 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.
(b) TennCare Select.
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 administrative costs.
1. The
TennCare 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 remains eligible.
(iii) Children 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
retardation.
(iv) Enrollees living
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.
2. TennCare Select also provides the
following functions:
(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.
(ii) 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).
(iii) It is the only entity responsible for
payment of the services described in
42 C.F.R. §
440.255, limited services for certain
aliens.
(c)
TennCare Managed Care Organizations (MCOs) for ECF CHOICES. Individuals
enrolled in ECF CHOICES may select from only the MCOs participating in ECF
CHOICES.
1. 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 CHOICES.
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.
(d) TennCare
Dental
Benefits Manager (DBM).
TennCare Enrollees shall be assigned to the Dental Benefits
Manager (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 or a 1915(c) Waiver program shall also receive Adult Dental
Services, as outlined in Chapter
1200-13-01.