CoverKids enrollees are enrolled into MCOs for the provision of covered medical
and behavioral health services, a DBM for provision of covered dental services,
and a PPA for administration of covered pharmacy services. 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
Managed Care Organizations (MCOs).
Individuals or families determined
eligible for CoverKids shall select an MCO at the time of application. The MCO
must be available in the Grand Division, as defined in Rule
, in which the
enrollee lives. All family members living in the same household and enrolled in
CoverKids must be assigned to the same MCO. An enrollee is given his choice of
MCOs when possible. If the requested MCO cannot accept new enrollees, the
Division of TennCare will assign each enrollee to an MCO that is accepting new
2. A CoverKids 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 the enrollee of
his MCO assignment, if there is another MCO in the enrollee's Grand Division
that is currently accepting new enrollees. No additional changes will be
allowed except as otherwise specified in this rule. 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
Division of TennCare 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
3. Each MCO shall offer its
enrollees, to the extent possible, freedom of choice among CoverKids providers.
If after notification of enrollment the enrollee has not chosen a primary care
provider (PCP), 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.
the event a pregnant woman entering an MCO's plan is :
(i) 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.
(ii) 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
Dental Benefits Manager (DBM). Children enrolled in CoverKids shall be assigned
to the DBM under contract with the Division of TennCare to provide dental
benefits through the CoverKids Program.
(c) Pharmacy Plan Administrator (PPA).
CoverKids enrollees shall be assigned to the PPA under contract with the
Division of TennCare to provide pharmacy benefits for both medical and
behavioral health services through the CoverKids Program.
Reassignment to an MCO other than the
current MCO in which the CoverKids enrollee is enrolled is subject to another
MCO's capacity to accept new enrollees and must be approved by the Division 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 paragraph (1), a
CoverKids enrollee may request a change of MCOs.
2. A CoverKids 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 CoverKids 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 CoverKids 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.
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 Division of TennCare 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 CoverKids shall also be changed.
A CoverKids enrollee may change MCOs if
the Division of TennCare 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.
following situations will not be determined to be "hardships":
(i) The enrollee is unhappy with the current
MCO or PCP, but there is no hardship medical situation (as stated in Part 2
(ii) The enrollee claims
lack of access to services but the plan meets the state's access
(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'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) An enrollee has a medical condition that
requires complex, extensive, and ongoing care; and
(ii) The enrollee's specialist has stopped
participating in the member's current MCO network and has refused continuation
of care to the enrollee in his current MCO assignment; and
(iii) The ongoing medical condition of the
enrollee 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 enrollee with the
current specialist; and
current provider of services is in the network of one or more alternative MCOs;
(vi) An alternative MCO is
available to the enrollee (i.e., has not given notice of withdrawal from the
CoverKids Program, is not in receivership, and is not at member capacity for
the member's region).
(c) Requests to change MCOs submitted by
CoverKids enrollees shall be evaluated in accordance with the hardship criteria
referenced in Subparagraph (b) 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 CoverKids will be assigned to the new MCO. Upon denial of a request
to change MCOs, enrollees shall be provided notice and appeal rights as
described in applicable provisions of Rule .09.
(d) The Division of TennCare shall only
accept a request to change MCO assignment from the affected enrollee, his
parent, guardian, or spouse.
Tenn. Comp. R. &
New rule filed January 11, 2021; effective
Authority: T.C.A. §§
4-5-204, 71-3-1106, and
42 U.S.C. §§
1397aa, et seq.; and the Tennessee Title XXI
Children's Health Insurance Program State Plan.