Tenn. Comp. R. & Regs. 1200-13-21-.07 - COST SHARING

(1) There are no premiums or deductibles required for participation in CoverKids.
(2) Copays.
(a) The following services are exempt from copays:
1. Ambulance services.
2. Emergency services.
3. Lab and X-ray services.
4. Routine health assessments (well-child visits) and immunizations given under American Academy of Pediatrics guidelines.
(b) The following copays are required, based on the enrollee's household income:

Service

Copay When Household Income is Less than 200% FPL

Copay When Household Income is Between 200% FPL and 250% FPL

MEDICAL BENEFITS

Chiropractic care

$5 per visit

$15 per visit

Emergency room

$10 copay per use for non-emergency

$50 copay per use for non-emergency

Hospital admissions and other inpatient services

$5 per admission

(waived if readmitted within 48 hours for same episode)

$100 per admission

(waived if readmitted within 48 hours for same episode)

Inpatient mental health and substance abuse treatment

$5 per admission

(waived if readmitted within 48 hours for same episode)

$100 per admission

(waived if readmitted within 48 hours for same episode)

Outpatient mental health and substance abuse treatment

$5 per session

$15 per session

Physical, speech, and occupational therapy

$5 per visit

$15 per visit

Physician office visit

$5 per visit (primary care); $5 per visit (specialist)

$15 per visit (primary care); $20 per visit (specialist)

Prescription drugs

$1 generic;

$3 preferred brand;

$5 non-preferred brand

$5 generic;

$20 preferred brand;

$40 non-preferred brand

Vision services

$5 for lenses; $5 for frames (when lenses and frames are ordered at the same time, only one copay is charged)

$15 for lenses; $15 for frames (when lenses and frames are ordered at the same time, only one copay is charged)

DENTAL BENEFITS

Dental services

$5 per visit

No copay for routine preventive oral exam, X-rays, and fluoride application

$15 per visit

No copay for routine preventive oral exam, X-rays, and fluoride application

Orthodontic services

$5 per visit

$15 per visit

(3) An enrollee's annual cost sharing obligations shall not exceed five percent (5%) of his household's annual income.
(4) Eligible children who do not pay a required copay remain enrolled in the program. An individual provider may at his discretion refuse service for non-payment of a copay unless a medical emergency exists. The state does not participate in collection action or impose any benefit limitations if enrollees do not pay their copays.
(5) Children receiving hospice services are exempt from all copay requirements.
(6) Pregnant enrollees are exempt from all copay requirements.

Notes

Tenn. Comp. R. & Regs. 1200-13-21-.07
Original rules filed November 28, 2018; effective February 26, 2018. Rule was originally numbered 1200-13-21-.05 but was renumbered 1200-13-21-.07 with the introduction of new rules 1 20013-21-.04 and 1200-13-01-.06 filed January 11, 2021; effective April 11, 2021. Amendments filed January 11, 2021; effective 4/11/2021.

Authority: T.C.A. §§ 4-5-202, 4-5-203, 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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