Tenn. Comp. R. & Regs. 1200-13-21-.04 - ENROLLMENT AND REASSIGNMENT

(1) Enrollment. 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 area.
(a) Managed Care Organizations (MCOs).
1. 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 1200-13-13-.01, 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 enrollees.
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 MCO.
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.
4. In 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 .10.
(b) 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.
(2) Reassignment.
(a) 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.
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 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.
(b) 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.
1. The 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 below);
(ii) The enrollee claims lack of access to services but the plan meets the state's access standard;
(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.
2. 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
(v) The current provider of services is in the network of one or more alternative MCOs; and
(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.

Notes

Tenn. Comp. R. & Regs. 1200-13-21-.04
New rule filed January 11, 2021; effective 4/11/2021.

Authority: T.C.A. §§ 4-5-202, 4-5-204, 71-3-1106, and 71-3-1110; 42 U.S.C. §§ 1397aa, et seq.; and the Tennessee Title XXI Children's Health Insurance Program State Plan.

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