Tenn. Comp. R. & Regs. 1200-13-14-.05 - ENROLLEE COST SHARING

(1) Premiums and deductibles.
(a) Enrollees are not required to pay premiums for TennCare.
(b) There are no TennCare deductibles.
(2) Copays.
(a) The following TennCare Standard enrollees are exempt from TennCare copays:
1. Enrollees who are receiving hospice services and who provide verbal notification of such to the provider at the point of service.
2. Enrollees who are pregnant and who provide verbal notification of such to the provider at the point of service.
3. Enrollees who are enrolled in any of the following CHOICES or ECF CHOICES demonstration categories:
(i) The CHOICES 217-Like Group
(ii) The CHOICES 1 and 2 Carryover Group
(iii) The PACE Carryover Group
(iv) The ECF CHOICES 217-Like Group
4. Children who are enrolled in TennCare Standard and who have family incomes below 100% of poverty.
(b) The following TennCare services are exempt from TennCare copays for all enrollees:
1. Emergency services, including the seventy-two (72) hour emergency supply of a medication in an emergency situation, as described in Rule 1200-13-14-.11.
2. Family planning services and supplies.
3. Preventive services as identified in Rule 1200-13-14-.04.
(c) Pharmacy copays. The following TennCare Standard enrollees have pharmacy copays of $3.00 per covered brand name prescription and $1.50 per covered generic prescription:
1. TennCare Standard children with family incomes that are 100% of poverty or greater.
2. Enrollees in the Standard Spend Down program.
3. Enrollees in the CHOICES At-Risk Demonstration Group.
4. Adults age 21 and older in the Interim ECF CHOICES At-Risk Demonstration Group.
(d) Copays for other TennCare services. The following copays are applicable to TennCare Standard children, except children enrolled in ECF CHOICES.

Benefit

Copay if income is 0%-99% of poverty

Copay if income is 100%-199% of poverty

Copay if income is 200% of poverty or greater

Hospital emergency room use for non-emergency services (waived if admitted)

$0

$10

$50

Primary care provider services other than preventive care

$0

$5

$15

Community Mental Health Agency services other than preventive care

$0

$5

$15

Physician specialists and dentists

$0

$5

$20

Prescription or refill

$0

$3 for covered branded prescriptions and $1.50 for covered generic prescriptions

$3 for covered branded prescriptions and $1.50 for covered generic prescriptions

Inpatient hospital admission

$0

$5

$100

(e) Copays for non-emergency services provided in an emergency department are not required unless the hospital has first provided the enrollee with assistance in gaining access to a non-emergency services provider (a physician's office, health care clinic, community health center, hospital outpatient department, or similar provider). This requirement on the part of the hospital can be met if, before providing non-emergency care subject to copay, the emergency room staff recommends that the enrollee or the enrollee's caretaker call the 24/7 nurse staffed call center for the enrollee's MCO to obtain help in locating an available provider in the community, and offers to assist with placing a call to the call center.
(3) Aggregate cost-sharing cap.
(a) The aggregate cost-sharing cap is applicable only to TennCare copays incurred by TennCare Standard children with incomes at or above 100% of poverty and their TennCare family members.
(b) The aggregate cost-sharing cap is calculated by combining the TennCare cost sharing for all TennCare family members who have TennCare cost-sharing obligations, and may not exceed 5 percent of the family's annual income, prorated to a quarterly equivalent. Family income will be calculated using the same methodology used to calculate income for the determination of eligibility, and the family will be assigned to the corresponding income band to determine the standardized aggregate cap, which is based on the lower end of the income band. The following income bands and the corresponding aggregate annual caps will be used:

Income Bands

Poverty levels

Standardized Annual Aggregate Cap

1

0% - 99%

Not applicable

2

100% - 149%

5% of the amount that corresponds to 100% FPL

3

150% - 199%

5% of the amount that corresponds to 150% FPL

4

200% - 249%

5% of the amount that corresponds to 200% FPL

5

250% - 299%

5% of the amount that corresponds to 250% FPL

6

300% - 349%

5% of the amount that corresponds to 300% FPL

7

350% - 399%

5% of the amount that corresponds to 350% FPL

8

400% - 499%

5% of the amount that corresponds to 400% FPL

9

500% - 599%

5% of the amount that corresponds to 500% FPL

10

600% and over

5% of the amount that corresponds to 600% FPL

(c) Families of applicable TennCare Standard children are responsible for tracking their own incurred cost sharing obligations, including keeping copies of receipts and similar documentation, and notifying the Bureau of TennCare when they believe they have reached their aggregate cost-sharing cap for a particular calendar quarter.
(d) After receiving the information described in subparagraph (c), TennCare will notify families of applicable TennCare Standard children of the date when it has been determined that the aggregate cost-sharing cap, as prorated for the quarter, has been reached. When that occurs, there are no further TennCare cost-sharing obligations required for the remainder of the calendar quarter. Any TennCare copays that are paid by the family during the quarter after the family's aggregate cost-sharing cap, as pro-rated for that quarter, has been reached will be refunded to the family by TennCare.
(4) This paragraph applies to all TennCare Managed Care Contractors and providers.
(a) In accordance with 42 CFR § 447.53(e), providers may not refuse to deliver a covered service to an enrollee because of the enrollee's inability to make his copay.
(b) Managed care contractors participating in the TennCare program shall be specifically prohibited from waiving or discouraging TennCare enrollees from paying any applicable cost-sharing amounts.

Notes

Tenn. Comp. R. & Regs. 1200-13-14-.05
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-.05; new effective date February 12, 2003. Emergency rule filed December 13, 2002; effective through May 27, 2003. Public necessity rules filed June 3, 2005; effective through November 15, 2005. Public necessity rule filed July 1, 2005; effective through December 13, 2005. Amendments filed September 1, 2005; effective November 15, 2005. Amendments filed September 26, 2005; effective December 10, 2005. Public necessity rule filed December 29, 2005; effective through June 12, 2006. 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. Public necessity rule filed March 21, 2007; effective through September 2, 2007. Amendment filed June 11, 2007; effective August 25, 2007. Public necessity rules filed November 30, 2007; effective through May 13, 2008. Amendment to rule filed February 14, 2008; effective April 29, 2008. Emergency rule filed March 1, 2010; effective through August 28, 2010. Emergency rule filed July 26, 2010; effective through January 22, 2011. Amendment filed May 27, 2010; effective August 25, 2010. Amendment filed October 20, 2010; effective January 18, 2011. Repeal and new rule filed January 15, 2013; effective April 15, 2013. Emergency rules filed September 26, 2013; effective through March 25, 2014. Amendment filed December 17, 2013; effective March 17, 2014. Emergency rules filed July 1, 2016; effective through December 28, 2016. Amendments filed September 30, 2016; effective 12/29/2016.

Authority: T.C.A. §§ 4-5-202, 4-5-208, 4-5-209, 71-5-105, 71-5-109, Executive Order No. 23.

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